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CDC/ATSDR TAC Meeting 

The Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and 

Disease Registry (ATSDR) hosted their Tribal Advisory Committee (TAC) Meeting and 17th 

Biannual Tribal Consultation Session, August 8–9, 2017, at The Artesian Hotel in Sulphur, 

Oklahoma. During the course of the two-day meeting, TAC members held discussions with CDC 

and ATSDR representatives. Topics discussed included CDC’s budget, tribal strategies for 

connecting cultural practices in competitive funding opportunities, Zika virus response, and 

tribal public health priorities. 

TUESDAY, AUGUST 8, 2017

Opening Blessing

The opening session began with a prayer led by Lieutenant (Lt.) Governor Jefferson Keel, 

Oklahoma Area Delegate. Councilman Chester Antone, TAC chair and Tucson area delegate, 

called the meeting to order at 9:07 AM.

Lt. Governor Keel welcomed everyone and wished them all a comfortable stay at the Artesian 

Hotel, Casino & Spa. He gave a brief history of the hotel, previewed its facilities and encouraged 

the audience to explore the amenities. He also informed everyone that the Chickasaw Cultural 

Center would be hosting a dinner that evening and that arrangements for transportation to the 

center had been made. He acknowledged Heather Summers, Chickasaw Nation, for her 

excellent coordination skills in managing preparations between the TAC meeting at the Artesian 

Hotel and the Chickasaw Cultural Center. 

Lt. Governor Keel began the nomination process for the positions of TAC chair and co-chair, by 

respectfully nominating Councilman Antone and Vice President Jonathan Nez, TAC co-chair and 

Navajo area delegate, to continue serving in their respective capacities. President Alicia 

Andrew, Alaska area delegate, seconded the nomination. 

Vice President Nez greeted all tribal leaders and advisors. He congratulated Councilman Antone 

on his work and team. He concluded by stating that he looked forward to having a productive 

meeting. 

Councilman Antone replied by thanking Vice President Nez and moved the meeting along by 

announcing the next item on the agenda, the roll call. 

Roll call was taken by Priyanka Oza, public health advisor, Tribal Support Unit (TSU), Office for 

State, Tribal, Local and Territorial Support (OSTLTS), CDC. 

Members present for roll call: 
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• Alaska Area Delegate—President Alicia Andrew, Karluk IRA Tribal Council

• Bemidji Area Delegate—Representative Robert TwoBears, Ho-Chunk Nation of 

Wisconsin

• Great Plains Area Delegate—Chairman Robert Flying Hawk, Yankton Sioux Tribe

• Navajo Area Delegate—Vice President Jonathan Nez, Navajo Nation

• Oklahoma Area Delegate— Lt. Governor Jefferson Keel, Chickasaw Nation

• Phoenix Area Delegate—Councilwoman Delia Carlyle, Ak-Chin Indian Community

• Portland Area Delegate—Council Member Travis Brockie, Lummi Nation

• Tucson Area Delegate—Councilman Chester Antone, Tohono O’odham Nation

• Tribes-at-Large Delegate—President George Edwardson, Inupiat Community of the 

Arctic Slope

• Tribes-at-Large Delegate—Tribal Employee Byron Larson, Northern Cheyenne Tribe

• Tribes-at-Large Delegate—Tribal Councilor Bryan Warner, Cherokee Nation

[Quorum Met] 

Members absent:

• Tribes-at-Large Delegate—Board Member Darcy Morrow, Sault Ste. Marie Tribe of 

Chippewa Indians

Delegate vacancies: Albuquerque, California, and Nashville Areas

Councilman Antone introduced Dr. José Montero, designated federal official, CDC deputy 

director, and OSTLTS director. 

Dr. Montero thanked the TAC for their attendance and service. He welcomed Tribal Councilor 

Bryan Warner, Tribes-at-Large, as the newest TAC delegate. He invited other tribal leaders 

present to stand and be recognized. Chairwoman Cheryl Andrews-Maltais, stood up and was 

acknowledged. 

Dr. Montero turned the meeting over to Captain Carmen Clelland, associate director for tribal 

support, OSTLTS, CDC, and TAC Secretary.

Captain Clelland thanked Dr. Montero and introduced himself. He covered a few items for 

situational awareness and guidance. He turned the meeting over to Commander Damion 

Killsback, deputy associate director for tribal support, OSTLTS.

Commander Killsback introduced himself and provided logistic updates for the meeting,

highlighting the emergency exits, restrooms, restaurants, etc. He asked all participants to 

please speak into the microphones and state their names. Commander Killsback turned the 

meeting back over to Dr. Montero.

Dr. Montero read the regulations of the Unfunded Mandates Reform Act.
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Councilman Antone read the TAC Roles and Responsibilities. Councilman Antone turned the 

meeting back over to Captain Clelland.

TAC Business and TSU Briefing Update

Presenters

• Captain Clelland , PharmD, MPA, MPH Associate Director for Tribal Support, OSTLTS 

• Commander Killsback , PharmD, MPH Deputy Associate Director for Tribal Support, 

OSTLTS

Captain Clelland began by stating that TSU is paperless and has passed out all necessary TAC 

meeting materials on jump drives. He explained that, last year, TSU decided to increase the 

productivity of biannual TAC meetings. TSU worked with contract support from Deloitte to 

evaluate the Winter 2017 TAC Meeting. TSU staff brainstormed how the information received 

could be used to improve the TAC meeting structure. The following three priorities were 

evident upon completion of the evaluation:

• Identifying opportunities 

• Enhancing participant engagement 

• Seeking alternative meeting formats

TSU worked with Deloitte to develop an internal tool to track advice and recommendations 

provided by TAC members to improve future TAC Meetings. Captain Clelland concluded by 

stating that TSU will be doing a pilot. Captain Clelland solicited TAC delegates for questions. 

Councilman Antone concluded the session, as there were no questions from TAC delegates. 

CDC Office of the Director Updates

Presenter

• José Montero, MD, MHCDS, CDC deputy director, OSTLTS director

Dr. Montero began the CDC updates by formally announcing the appointment of Dr. Brenda 

Fitzgerald as the 17th director of CDC and the ATSDR administrator. Dr. Fitzgerald’s 

appointment was effective July 7, 2017. She previously served as commissioner of the Georgia 

Department of Public Health and was the state health officer from 2011 to 2017. 

Combatting the Opioid Epidemic

AI/AN populations continue to be disproportionately affected by various types of intentional 

and unintentional injuries, including opioid overdose. The rate of drug-related deaths among 

AI/AN populations has nearly quadrupled since 1999 and is now double the rate of the US 

population as a whole. Decades of disparities in employment opportunity, education, and 
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access to medical and mental health care have created an environment in which injury 

prevention efforts in AI/AN communities have not been as successful in comparison with nonNative communities of similar socio-economic status. Strategic collaboration to increase the 

cultural relevance of intervention strategies between tribal public health experts, tribal leaders, 

and the National Center for Injury Prevention and Control (NCIPC) has been successful in 

lowering death rates attributed to motor vehicle injuries in the past decade. Adequate funding 

is needed for effective, long-term change. 

Earlier this year, HHS Secretary, Dr. Thomas E. Price announced a five-part approach to combat 

the opioid overdose epidemic—

1. Strengthening public health surveillance

2. Advancing the practice of pain management

3. Improving access to treatment and recovery services

4. Targeting availability and distribution of overdose reversing drugs

5. Supporting cutting-edge research

Addressing a problem as complex as the opioid crisis requires collaboration among public 

health, clinical medicine, and public safety at the federal, state, and local levels. While this 

approach does not specifically address AI/AN populations’ needs, there are many ways CDC can 

ensure a population-specific approach. CDC’s specialty is bringing a public health approach to 

opioid overdose and prevention, which requires understanding the problem, developing 

effective solutions, and implementing those solutions through partnership with and funding of 

state programs.

NCIPC leads CDC’s efforts to fight the opioid epidemic, but many other centers run relevant 

programs. NCIPC released “CDC Guideline for Prescribing Opioids for Chronic Pain” in March 

2016 to help primary care doctors provide safer, more effective care for patients with chronic 

pain. The Guideline provides 12 voluntary recommendations for prescribing opioid pain 

medication for patients 18 and older in primary care settings. The Indian Health Service (IHS) 

has provided training to their clinical directors on practices that align with the Guideline. IHS 

has a chronic, non-cancer, pain management policy, which they amended to align with the 

Guideline. NCIPC leads three programs: 

• Prescription Drug Overdose: Prevention for States 

• Data-Driven Prevention Initiative

• Enhanced State Opioid Overdose Surveillance

These three programs work to improve access to treatment for opioid misuse, reduce opioidrelated deaths, and strengthen prevention efforts for drug abuse across 45 states, 4 tribes, and 

the District of Columbia. The funding also supports improved data collection and analysis 

around opioid abuse and overdose, as well as better tracking of fatal and nonfatal opioid-
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involved overdoses. States not funded for any of the programs are Iowa, Mississippi, North 

Dakota, Texas, and Wyoming. 

NCIPC has piloted a communication campaign that shares real stories from people whose lives 

have been affected by prescription opioid abuse and overdose. The campaign’s goals are to 

increase awareness that opioids can be addictive and dangerous Dr. Montero informed 

everyone that the campaign would launch in the next few months. CDC overdose prevention 

awardees will have access to campaign materials and will be able to tailor them to reach their 

residents. 

NCIPC has an interagency agreement (IAA) established in August 2016 with the IHS Office of 

Public Health Support, Division of Epidemiology and Disease Prevention, Tribal Epidemiology 

Centers (TECs). Through the IAA, CDC and IHS are working to improve the quantity and quality 

of injury reports available to AI/AN programs to reduce the health impact of intentional and 

unintentional injuries. The Albuquerque Area Southwest TEC, Navajo TEC, and Oklahoma Area 

TEC have been funded to develop unintentional and intentional injury atlases, reports on opioid 

use and suicides, and an evaluation guide for traffic safety programs. 

NCPIC hopes to engage IHS to explore the potential of a regional IHS office taking part in a

quality improvement (QI) collaborative to implement clinical QI measures based on CDC’s 

opioid prescribing guideline. This collaboration is scheduled to launch in January 2018. 

CDC’s Centers, Institutes, and Offices (CIOs) are also doing important work to prevent opioid 

overdoses in AI/AN communities nationally. 

CDC’s viral hepatitis program in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB 

Prevention (NCHHSTP) provides technical assistance (but not funding) for the “Path Toward 

Elimination of HCV” project. The project seeks to improve health by eliminating hepatitis C virus 

(HCV) among American Indians in the Cherokee Nation Health System. The second phase of the 

project includes using community-based efforts to implement interventions to stop 

transmission of HCV, primarily among people who use inject drugs. The viral hepatitis program 

is also assessing programs proven to be effective, such as screenings for people who inject 

drugs in order to reduce illness and deaths among Alaska Natives. 

NCHHSTP is also working with IHS on an analysis of existing data sources that could inform IHS 

about regions and counties at potential risk for spread of HIV and HCV infection associated with 

injection drug use to identify priority localities for HIV and HCV prevention and harm-reduction 

interventions. The project will produce peer-reviewed summary reports and presentations to 

IHS and partners to guide prevention and care efforts. 

NCBDDD is working to improve the availability and quality of data to help inform clinical 

management decisions for health care providers of women of all races and ethnicities who are 

pregnant or could become pregnant. Currently, CDC is supporting two pilot projects on
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neonatal abstinence syndrome (NAS) to better understand the incidence, severity, and longterm developmental and educational outcomes associated with NAS. The “Treating for Two: 

Safer Medication Use in Pregnancy” initiative tracks trends in prescription opioid use among 

pregnant women and women of reproductive age to monitor the opioid epidemic in the United 

States.

NCCDPHP’s Division of Reproductive Health has conducted an Epi-Aid on the prevalence of 

maternal substance use (including opioids and NAS) in the Sisseton Wahpeton Oyate and the 

Cheyenne River Sioux Tribes. An Epi-Aid is a mechanism for public health authorities to request 

short-term assistance of CDC Epidemic Intelligence Service officers to respond to an urgent 

public health issue. Epi-Aid activities in this area include providing claims data and documenting 

substance use during pregnancy. 

Tribal Public Health Authority and Tribal Epidemiology Centers

Originally passed in 1976 and subsequently amended, the Indian Health Care Improvement Act 

(IHCIA) declared, “it is the policy of this Nation, in fulfillment of its special responsibilities and 

legal obligation to the American Indian people, to ensure the highest possible health status for 

Indians and urban Indians and to provide all resources necessary to effect that policy.” IHCIA 

established the legal and programmatic structure for providing health services to AI/AN 

populations. 

The 1992 amendments to IHCIA authorized the establishment of TECs to serve each IHS region. 

TECs perform a variety of functions—in consultation with and at the request of Indian tribes, 

tribal organizations, and urban Indian organizations—to elevate the health status of these 

communities. TECs do so by carrying out activities that include the following: 

• Collecting and monitoring data on the health status objectives of IHS, Indian tribes, 

tribal organizations, and urban Indian organizations

• Evaluating delivery and data systems that affect Indian health and assisting tribes, tribal 

organizations, and urban Indian organizations to determine health status objectives and 

services needed to meet those objectives

• Making recommendations of services to assist Indian communities and to improve 

Indian healthcare delivery systems

• Providing technical assistance to tribes, tribal organizations, and urban Indian 

organizations to develop local health priorities and disease incidence and prevalence 

rates

• Providing disease surveillance and promoting public health 

In 1996, the Health Insurance Portability and Accountability Act authorized TEC access to data 

held by HHS. In 2010, Congress enacted the Patient Protection and Affordable Care Act (ACA),

which permanently reauthorized IHCIA. IHCIA’s 2010 reauthorization included a provision 

designating TECs as public health authorities. 
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Adequate access to AI/AN public health data is a continuing issue for TECs. Access to data is 

essential to performing TEC functions successfully. To secure AI/AN health data, TECs often 

collaborate with other jurisdictions, including state, local, and federal agencies. Data-sharing 

agreements make some of these data requests possible. State and local jurisdictions do not 

always have data-sharing agreements with TECs, which can cause delays. Some jurisdictions 

require fees to acquire the data. TECs also face difficulties securing relevant data, fostered by a 

concern from state and local jurisdictions and private entities regarding the release of 

identifiable health data, as well as by state laws limiting access to certain health data.

Tribal Accreditation Support Initiative 

The OSTLTS Accreditation Support Initiative (ASI) is a direct funding initiative to help health 

departments prepare for public health accreditation. ASI will award up to $10,500 to 20 eligible 

Tribal entities in fiscal year (FY) 2018. There is a separate funding category for tribes new to 

public health accreditation. This category will allow Tribal entities to explore—in-depth and in a 

cohort of beginners—the potential of achieving public health accreditation with the option of 

taking the first steps on the accreditation path. Applications are due September 1, 2017.

Emergency Preparedness and Response

CDC’s Office of Public Health Preparedness and Response (OPHPR) funds the Public Health Law 

Program (PHLP) in OSTLTS to develop legal resources related to tribal emergency preparedness 

law. The program received $75,000 in FY 2016 and $75,000 in FY 2017 to develop a training 

protocol and resource compendia that tribes can use to help them prepare for public health

emergencies. 

In the project’s first year and early in its second year, facilitators met with more than 100 tribal 

leaders and elders, tribal emergency responders and coordinators, and tribal coordinators 

within public health departments who partner and closely work with tribes from multiple 

regions of the country including the Northwest, Midwest, Southeast, West, and Washington, 

DC. 

PHLP has developed tribal emergency preparedness legal resources used by

• Tribes developing and updating their public health codes

• TECs navigating public health data sharing issues with state, local, and tribal partners

• Federal, state, and local agencies seeking to better understand tribal sovereignty and 

authorities on public health issues 

Tribal involvement in the Zika virus response activities of CDC’s Emergency Operations Center 

(EOC) included the following: 

• CDC subject matter experts collaborating with Indian-serving partners, such as AAIP and 

the National Indian Health Board (NIHB), to provide briefings during Zika-specific calls 

hosted by these organizations 

• CDC subject matter experts giving presentations to various audiences on Zika-related 

topics, including vector control, transmission concerns, epidemiology and surveillance, 
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pregnancy and birth defects, laboratory science, traveler and border health, and blood 

safety

• Tribal partners participating in routine calls with states throughout the Zika response 

• Tribal leaders from nations in affected states attending the Zika Action Plan Summit, in 

Atlanta, Georgia, in April 2016 and initiating a coordinated response dialogue with the 

states 

In addition, the EOC’s State Coordination Task Force created the Tribal Liaison Officer (Tribal 

LNO) position on July 7, 2016. The Tribal LNO works closely with HHS and its operating divisions, 

OPHPR and other CDC programs, tribal governments, organizations, and communities during an 

emergency preparedness event. Tribal LNO duties include reporting tribal activities at key 

briefings and informational meetings, gathering and sharing critical tribal response information, 

and being alert to the direction the response is taking and how that direction will affect tribes 

and tribal communities. 

CDC’s Epidemiology and Surveillance Capacity 

The TEC Directors’ Annual Meeting was held in Portland, Oregon, on March 23, 2017. Dr. 

Montero and Dr. Bauer, director, National Center for Chronic Disease Prevention and Health 

Promotion (NCCDPHP) attended the meeting to provide updates and information about OSTLTS 

and NCCDPHP work in Indian country, respectively. The TEC directors provided feedback about 

how CDC can better support their work, new approaches, and new partnerships. 

Workforce Development 

The Public Health Associate Program (PHAP) expansion into Indian Country for FY 2016 included 

nine PHAP associates. The 2017 matches and offers are in progress and will be shared when the 

process is completed. Below is the list of current PHAP host sites working in tribal public health: 

• Choctaw Health Center, Choctaw, Mississippi

• Eastern Band of Cherokee Nations’ Public Health and Human Services Division, 

Cherokee, North Carolina

• Indian Health Service Field Office (also working with CDC), Albuquerque, New Mexico

• Indian Health Service Headquarters’ Division of Epidemiology and Disease Prevention, 

Rockville, Maryland

• Maniilaq Association, Kotzebue, Alaska

• Montana Department of Public Health, Helena, Montana

• North Dakota State University, Fargo, North Dakota

• Rocky Mountain TEC, Billings, Montana

• Southcentral Foundation, Anchorage, Alaska 

TAC Questions and Discussion

Councilman Antone solicited TAC Delegates for questions. 

Chairwoman Andrews-Maltais explained that as a tribe, they are finding heroin has become a 

problem in the Northeast. She posed the question, “Is there a way to encourage changing the 
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language of FOAs to be more inclusive of tribes? The language leaves many tribes out. If we 

have a few thousand dollars, we are able to stretch that dollar further than most.”

Dr. Montero acknowledged the rising opioid epidemic. He expressed the need for a long-term 

strategy to address the opioid epidemic. He stated that in addition to opioids, the language 

should include drugs such as heroin. Dr. Montero also stated that CDC had to proceed with 

caution when editing funding language as not to misrepresent or misstate anything. He 

informed Chairwoman Andrews-Maltais that a meeting would take place that coming Friday to 

discuss funding mechanisms and incorporating traditional values and medicine in Notice of 

Funding Opportunity Announcements (NOFOs). Dr. Montero concluded by stating that Dr. 

Bauer would speak more about NOFOs later. 

President Edwardson introduced himself. President Edwardson informed everyone that about 

three weeks prior to the Summer TAC meeting, his tribe joined forces with their local police 

commander to work together to combat the opioid epidemic. 

Dr. Montero acknowledged the efforts of President Edwardson’s tribe and local community. 

Councilman Antone discussed a previous meeting held with former CDC Director Dr. Tom

Frieden and a few tribal leaders. He informed the audience that the topics of discussion 

included suicide and substance abuse. He posed the following questions for Dr. Montero: 

• How many partners or agencies has CDC partnered with to address public health 

concerns in Indian Country? 

• What eligibility criteria was established for the Public Health Emergency Preparedness 

(PHEP) NOFO? 

• Does the NOFO have tribal language for opioid addiction funding? 

• Are tribes eligibile to apply for the NOFO? 

• Which funding opportunities will be allocated to states and which will be considered for 

tribal and local health departments?

Dr. Montero explained that the NOFO included language about tribal eligibility for opioid 

addiction funding, but he did not have the language available to him at that time. He stated 

that there was specific language and some of the funding would go to tribes. He offered to send 

the NOFO eligibility criteria language to the TAC. Dr. Montero concluded by stating that he 

would get the information on the language explaining how much funding will go to states and 

how much flexible funding could be allocated to tribes. 

Councilman Antone thanked Dr. Montero for his efforts. Dr. Montero responded by informing 

the TAC delegates that CDC intends to provide answers and better follow-up following all 

current and future TAC meetings.

Lt. Governor Keel stated that the recent NOFO (due the previous day) for the public health 

infrastructure was only available to TECs. He asked Dr. Montero how tribes would be included.
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Dr. Montero yielded his time and the floor to Dr. Bauer, and Lt. Gov. Keel decided to wait for a 

response until the budget portion of the presentations. 

Councilman Antone invited Chairwoman Andrews-Maltais to express her concerns. Ms. 

Andrews-Maltais expressed her concern for money going into Indian Country of which tribes 

are unaware. She stated that 50% of funding in Indian Country went through the states, but the 

tribes never received it. She suggested that if CDC could allocate funding for tribes that may

help tribes get their portion. Dr. Montero informed Chairwoman Andrews-Maltais that CDC 

would consider her idea. 

Zika Virus Update

Presenter

• Stephanie Dulin , MBA, Deputy Director, National Center on Birth Defects and 

Developmental Disabilities (NCBDDD) 

In this session, Ms. Dulin presented on short- and long-term health consequences associated 

with Zika, and she described the US Zika Pregnancy and Infant Registry (USZPR). The purpose of 

the USZPR is to monitor pregnancy and infant outcomes following Zika virus infection during 

pregnancy and to inform clinical guidance and public health response. The system monitors 

pregnant women with laboratory evidence of Zika virus infection and exposed infants born to 

these women, as well as infants with laboratory evidence of congenital Zika virus infection and 

their mothers. CDC coordinates this supplemental surveillance effort, which depends on the 

voluntary collaboration of state, tribal, local, and territorial health departments. 

Ms. Dulin invited tribes to spread the word about the registry’s importance as well as 

encourage healthcare providers to work with their state, tribal, local, or territorial health 

departments. She stated that healthcare providers could work with these departments to:

• Report cases to the registry 

• Collect clinical and follow-up information for pregnant women and infants who are part 

of the registry

• Provide information to health departments or directly to the registry, if asked to do so 

by local health officials, and notify health department or registry staff of adverse events 

She described several tribal engagement efforts in progress, including targeted communication,

CDC Emergency Response Team deployment to tribes before an emergency, Tribal Zika 

summits, webinars and trainings, and more. Ms. Dulin also described collaboration activities, 

including a cooperative agreement with NIHB, the April 2016 Zika Action Plan Summit, technical 

assistance for tribes, American Mosquito Control Association trainings, and more. She 

concluded by describing Zika Care Connect, a healthcare professional web-based network 

formed in collaboration with March of Dimes and designed to improve access to clinical 
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services. Zika Care Connect includes a referral network to identify specialty healthcare 

providers, and information for healthcare professionals caring for patients with Zika. 

The floor opened for questions, and Lt. Governor Keel asked if any AI/AN children have been 

reported to be infected with the Zika virus. He also wanted to know specifically the symptoms 

and conditions affecting tribal children and the support systems available to these children and 

their communities. 

She explained that the majority of that work has been done through IHS. Ms. Dulin responded 

by stating that she would look into this and report back. She went on to clarify that the image in 

her PowerPoint Presentation represents a severe case of Zika. She did not have the data 

present to show what percentage of cases have congenital Zika syndrome, nor if cases are 

broken out by type of anomaly.

Lt. Governor Keel also asked how tribal health systems will be able to access vaccines and if the 

vaccines would be in their formularies. 

Ms. Dulin replied that the vaccines are being developed by private companies with public funds 

and dissemination is being discussed. She assured the audience that she would provide updates 

on the matter. 

Chairwoman Andrews-Maltais added that AI/AN populations are often not included in vaccine 

testing. She asked what efforts are being made to reach out to tribes and tribal women to make 

sure that the vaccines are as effective for AI/AN people as they are for others.

Ms. Dulin responded by stating that the Biomedical Advanced Research and Development 

Authority (BARDA) is leading vaccine development. She will check with them regarding AI/AN 

inclusion in testing. 

Chairwoman Andrews-Maltais also asked if there is a best practice for prevention. She 

suggested that since there are tribal members throughout the country, CDC could provide 

prevention info throughout networks. 

Ms. Dulin replied that most of the cases in our country have been travel-associated cases, and 

did not originate in United States. The Zika website has guidance on both testing and 

prevention. CDC is still telling pregnant women not to travel in areas with high Zika prevalence, 

and that they should be careful about conception, especially if their partner has traveled to an 

area with a high Zika prevalence.
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Chairwoman Andrews-Maltais also asked if Zika testing is mandatory as part of typical 

pregnancy testing. 

Ms. Dulin replied that CDC’s guidance is to test symptomatic women or at high risk who are 

asymptomatic. However, some jurisdictions still prefer to monitor.

Mr. Larson asked how CDC is collaborating with tribes on surveillance. 

Regarding what has been done with TECs, she stated she would have to defer to CDC staffs who 

have worked in the EOC’s Tribal LNO role, which include TSU Staff members Delight Satter and 

Nicolas Rankin. She encouraged calls to come directly to CDC for additions to the registry. She 

concluded her response by stating that CDC’s intent regarding Zika surveillance is that all cases 

are monitored.

Councilman Antone concluded the session by emphasizing the importance of documenting 

statistics on tribal nations. 

Budget Overview 

Panel participants

• Jenny Sewell, JD, MPA, Public Health Analyst, Congressional Team, Office of 

Appropriations, Office of Financial Resources, CDC

• Georgia Moore, MS, Associate Director for policy, OSTLTS, CDC

• Ursula Bauer, PhD, MPH, Director, NCCDPHP 

Ms. Sewell and Ms. Moore provided a FY 2017 Budget Summary. Dr. Usula Bauer also provided 

an update on funding from her center, NCCDPHP. 

Ms. Sewell described the FY 2017 distribution of CDC’s $7.2 billion in funding. Compared to FY 

2016, there were decreases in funding for the following areas: 

• Environmental health (-$1.7 million), 

• Workforce (-$2.2 million) and occupational safety (-$3.9 million)

• Immunization (-$4.1 million)

• Sexually transmissible infections (-$5.0 million)

• Tobacco (-$5.0 million)

• Heart disease and diabetes (-$30 million each)

Funding increases included the following:

• Birth defects ($2.0 million)

• National Diabetes Prevention Program ($2.5 million)

• Global Health ($8.0 million)
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• Opioid overdose prevention ($50 million)

She described the President’s budget request for FY 2018 would decrease CDC’s budget from 

$7.2 billion in FY 2017 to $5.976 billion. Major changes between FY 2017 enacted funding and 

the President’s FY 2018 budget included these decreases:

• Environmental health activities (-$23.8 million)

• Antibiotic resistance initiative (-$26.0 million)

• Public health surveillance and informatics, workforce, and statistics (-$29.4 million)

• Birth defects programs (-$37.6 million)

• Immunization program (-$93.5 million)

• Public health emergency preparedness grant program (-$109.0 million)

• Occupational safety and health (-$135.2 million)

• Preventative Health and Health Services (PHHS) Block Grant eliminated (-$160 

million)

• Chronic disease prevention activities (-$163.3 million)

• HIV, STD and TB activities (-$183.3 million)

The FY 2018 House Appropriations Committee budget estimates for CDC are:

• CDC’s overall FY 2018 program level is $7,001.5 million, a decrease of $198.4 million 

compared to FY 2017 

• The House proposal does the following:

o Eliminates funding for the Racial and Ethnic Approaches to Community Health 

(REACH) program

o Maintains funding for the Good Health and Wellness in Indian Country (GHWIC) 

program at $16 million and prohibits CDC from decreasing funding for the 

program and from other chronic disease lines 

o Specifically does not fund the America’s Health block grant proposed in the 

President’s Budget

o Maintains funding for the current PHHS Block Grant at $160.0 million

Ms. Moore presented updates on CDC and ATSDR funding to tribes and tribal organizations and 

committed to providing an analysis of funding supporting tribes by the Winter 2018 TAC 

meeting. She explained that the analysis is not always straightforward because of the way 

funding streams are documented. As a result, it may take further investigation after the Winter 

TAC meeting to get the full information TAC members have requested. For example, funding by 

sub-grantees is documented in grantee individual work plans maintained by their respective 

project officers. Ms. Moore concluded by stating that the funding is difficult to track and will 

take some time. 
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Dr. Bauer provided an update from NCCDPHP. She explained that CDC operated under a 

continuing resolution for the beginning of FY 2017. During that time, CDC deployed its funding 

as directed. At that point, NCCDPHP had $50M for one of its public health program. When CDC 

received its budget in May, NCCDPHP was allocated $34M for that program, a $14M decreased 

from the $50M decided on during the continuing resolution. They also learned they had $16M 

for the REACH program. To cover the deficit between the $50M and the $34M, NCCDPHP pulled 

money back from REACH programs that they had already deployed. NCCDPHP also found some 

internal efficiencies and cancelled some contracts in order to deploy funding to tribal programs. 

Dr. Bauer described NCCDPHP’s support for TECs. Specifically, NCCDPHP designed its plan to 

support TECs to be consistent with Congress’s message to CDC to increase support for TECs. 

NCCDPHP deployed about $8.5M to TECS to follow through with directives from the President 

and Congress. With the funds deployed yesterday (August 7, 2017), NCCDPHP has about $3M 

left to support a NOFO in the fall for tribes and Urban Indian Health Centers. With this funding, 

NCCDPHP will follow through on the TAC’s request to find out what traditional practices keep 

AI/AN populations well. In addition, NCCDPHP will make progress in supporting cultural 

practices and learning what connects people to culture. Funding recipients will be able to 

decide how to spend the dollars. NCCDPHP designed the NOFO based on several years of 

dialogue and input from tribal convenings, NIHB listening sessions, and meetings with Indian 

Health Boards (IHBs) and tribes. Tribal participants in these meetings have recommended 

funding amounts ranging from $75,000 to $150,000. Dr. Bauer concluded by stating that she 

would like the TAC’s input on those amounts so NCCDPHP can fund as many tribes as possible 

with adequate resources. 

Melanie Fourkiller, Policy Analyst from Choctaw Nation Health Services, raised the need for 

consistent and reliable funding for tribal public health infrastructure. She explained that tribes 

have primary responsibility for infrastructure—not TECs, or IHBs. Tribes partner with states and 

locals, but to do so they need to carve from funds they receive for treatment and care. State 

governments get funding for infrastructure, so tribes really want CDC to continue not only to 

emphasize, but also to provide a reliable and consistent source of funding to tribes for 

infrastructure that does not have to be negotiated each year. 

Ms. Fourkiller further explained that while it is nice to see tribes eligible for NOFOs—public 

health emergency response funding, for example - tribes still need to compete for them, and 

the capacity to compete with entities that have so much more infrastructure and capacity is not 

present in Indian Country. She suggested another approach, which would be for tribes to 

compete among themselves for a percentage of CDC’s budget that is designated for Indian 

Country. 
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Regarding the NOFO that Dr. Bauer had mentioned was released August 7th, Ms. Fourkiller 

asked if there was a directive to restrict that to TECs, or if CDC was required to restrict it in 

some way. She highlighted the fact that $42 million is a lot of money.

Dr. Bauer responded that the $42 million would fund activities over five years, which is 

equivalent to about $8.5 million each year. She reiterated that CDC followed through on the 

directive in the President’s proposal and that the NOFO was developed over a couple of years.

The GHWIC grant budget also changed, causing NCCDPHP to focus their grant funding on 

chronic disease outcomes. She went on to explain that for both the GHWIC and the new budget 

line, CDC plans a couple of years in advance for a number of years. CDC assesses what is needed

in Indian Country, and what opportunities CDC would like to seize or create. Dr. Bauer stated 

that because they had planned ahead, NCCDPHP was prepared when they received the new 

budget line. 

Dr. Bauer stated she would like input on how best to support tribal health departments. 

Questions she would like input on include the following:

• How much funding per tribe is adequate? 

• How should funding be disseminated and to how many tribes—all or some? 

• Should dissemination of funds start with larger tribes? 

Dr. Bauer stated that she would be willing to help in any way she is able. She concluded by 

stating that if the planning process started now, NCCDPHP would be ready if another

opportunity opens up. She clarified that while CDC does not do advocacy, tribes would need to 

determine if and how to advocate for funding. 

Mr. Larson shared that the biggest issue is the parity tribes want between state and local health 

departments, and that the federal government gives resources to them to execute services to 

tribal populations. Mr. Larson stated that tribal needs must be clarified so tribes have a basis 

for requesting 2% of CDC CIO budgets. He concluded by emphasizing the need to develop a 

framework for that discussion so tribes can be assertive in their request for 2% of CDC’s budget.

Ms. Moore shared that an innovative emergency response NOFO is expected. From her 

understanding, it will identify tribal response opportunities and capacities, so that when a tribe 

is in need of an emergency response, CDC can look in this queue and match funding capacity to 

reach tribes. 

TSU is also working on a tip sheet for project officers who write NOFOs in an effort to address 

the issue of tribes competing with states for funding. For example, it would guide project 

officers to state explicitly in the NOFO any intent to reach a certain number of tribes. CDC 
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would still rank the proposal, but would look at separate rankings for states, tribes, and large 

cities, and fund as many from each group as possible. Regarding opportunities, there currently 

is a lot of concern and focus on rural communities. This focus provides another opportunity to 

talk about, and reach, tribes. Ms. Moore encouraged the participants to collaborate. 

Dr. Bauer added that her center does struggle due to the large number of Federally Recognized 

Tribes (567). She explained that NCCDPHP does fund tribes directly and meets the 2% 

threshold. She requested TAC members to give her ideas on specific funding arrangements that 

would provide adequate, consistent, reliable funding. Dr. Bauer concluded by giving the 

following examples: a five-year funding term, a formula instead of a competition, or some other 

approach.

Lt. Governor Keel explained that though 567 is a large number of tribes, not all of the tribes 

have health systems that would apply or have a need. Several tribes are doing well in some 

areas, but all of them need some help. He explained how it’s possible to group tribes in 

different ways. For example, there are 227 in Alaska and 330 in the lower 48 states. Many have 

consolidated their efforts with other tribes, so they could be considered together for funding

(i.e., tribes in Alaska). 

Lt. Governor Keel went on to explain that although many states have good relationships with 

tribes, most do not because there is no legislation stating they need to work with tribes. 

Pandemic flu and Homeland Security were exceptions since legislation allowed for tribes to get 

funding directly. He stated that though it is up to tribes to advocate to Congress, CDC has to be 

the advocate when we talk about public health, and to get people to include direct funding to 

tribes in legislative language. Sometimes agencies use legislative language as a crutch to avoid 

or justify not funding tribes.

Mr. Warner stated that he is brand new to the committee and it is an honor. He asked if 

Congress directed CDC to make the new NOFO open only to TECs, or if CDC made that decision.

Dr. Bauer explained that CDC responded to a Congressional directive that half the funding 

needed to go to TECs. The language was crafted over the past two years with input from the 

TAC and others, and with language from Congress regarding stronger support for the TECs. 

President Andrew stated that when people hear there are 229 tribes in Alaska alone it might

scare them. However, she mentioned that Alaska has a consortium in Anchorage that has a 

funding formula. She also emphasized that all the people in those tribes matter, even those in 

the smallest tribes.
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Dr. Bauer expressed her appreciation for this dialogue. She appealed to Councilman Antone 

that it would be helpful to have a proposal from the TAC describing their recommendation for 

who and how to fund tribal activities. Dr. Bauer emphasized that there is a lot of support, and 

having a game plan would make it is easy to move forward—having a game plan helped move 

forward the FY 2017 activities that got funded. 

Councilman Antone asked Ms. Moore and Dr. Bauer if TSU provides them with information on 

what the tribal needs are as they formulate the President’s budget. 

Ms. Moore answered, “Absolutely.” She explained that she constantly get inputs on tribal 

needs, including getting appraised of travel to Indian Country and input received from those 

site visits.

Chairwoman Andrews-Maltais added that doing the Special Diabetes Program for Indians (SDPI)

has worked for her tribe. 

Dr. Montero added that TSU has contracted with NIHB to conduct a scan of public health 

capacity in Indian Country. He stated he is not aware of the number of tribes that have a public 

health department or the number of tribes that rely on the TECs. He stated that in order to be 

effective, CDC and tribes need to be able to articulate the illness burden and the capacity. 

“Often times, the 2% funding number allows us to get sidetracked, but unless the budget 

request can be documented with the public health need, we won’t be ready to justify the 

budget requests.” Dr. Montero informed everyone that the information on public health needs 

and capacity does not exist, so the scan being conducted is incredibly important. Dr. Montero 

emphasized that anything TAC delegates can do to help support the scan, including telling CDC 

with whom to work, is incredibly important because it will provide the much-needed baseline

information. 

Councilman Chester Antone concluded the session. 

Welcome and Overview of Chickasaw Nation Public Health Programs

Panel participants

• Heather Summers, MS, RN, Under Secretary of Operations, Hospitals and Clinics, 

Chickasaw Nation

• Bobby Saunkeah, RN, MSGCE, CIP (Kioawa Tribe), Manager, Research and Population 

Health Division, Chickasaw Nation Department of Health (CNDH)
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• Valarie Blue Bird Jernigan, DrPH, MPH (Choctaw Nation), Associate Professor, Health 

Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences 

Center 

• Miranda Willis, Data Analyst, Strategic Prevention, Chickasaw Nation 

Mr. Saunkeah gave a few details on the background of native presence in Oklahoma. At around 

400,000 Indigenous folks, Oklahoma has the second largest Native American population in the 

United States, second to the state of California. About 45% of the population resides in urban 

areas, such as Tulsa and Oklahoma City. Due to the fact that it is not a reservation-based state 

there is a lot of diversity. There are about 38 federally recognized tribes, 18 non-federally 

recognized tribes, and 28 different tribal languages in the state. There is no Pan-Native 

American culture as the Native communities are blended communities. The Native population 

is integrated with the general population, so public health services impact non-Native folks, as 

well as Chickasaw Nation citizens. Oklahoma’s diversity presents unique challenges when 

applying for grants because the community is often pre-defined for them. The panel members 

suggested that the definition of community be less strict on NOFOs. By not strictly defining 

community, the tribes will be able to define what community means to them and how it is 

composed. 

The main issue with tribal data is that there is a lack of quality public health data in terms of 

demographics. The panel members explained that Chickasaw Nation uses data from electronic 

health records to reflect what the population data are. Since public health data is difficult to 

collect for tribes, tribes are using clinical data instead. Panel members acknowledged that while 

this approach is not always better, it is the best they can do to collect data because a tribal 

health system is a closed system. 

A few details on the services provided by the Chickasaw Nation Department of Health (CNDH)

were provided. CNDH has added a new mobile prevention service unit, nurses, staff members 

who deal with informatics, and a health promotions director. They explained that funding for 

this department is carved out from other areas, causing the other programs not to grow. This 

issue emphasizes the need for direct funding for tribes to build the public health workforce and 

infrastructure in Chickasaw Nation. They stated that CNDH has received the Tribal ASI grant 

from NIHB to facilitate accreditation. CNDH has a representative from every major department 

as all 10 essential public health services occur in every department. External stakeholders 

include organizations like the Robert Wood Johnson Foundation and NIHB. CNDH is the only 

tribal community to be a Robert Wood Johnson sentinel community—a community recognized 

for developing its own culture of health and known for innovation and fostering of community 

engagement. In addition, Oklahoma University Health Sciences Center has a clinical and 

translational research center grant.

Dr. Jernigan explained that her research focuses on intervention methods. She enjoys working 

with Chickasaw Nation to make science rigorous and feasible. She emphasized how valuable 
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partnerships are for the intervention process. A few projects CNDH is currently implementing 

include mobile food basket study and initiatives on farmers markets. 

Mr. Saunkeah provided details on intervention efforts CNDH is involved with to combat 

childhood obesity. CNDH hosts non-competitive and family focused 5K runs and walks to 

combat childhood obesity. In addition to runs and walks, CNDH has two mobile units: the 

Inchokma Medical Unit, a mobile unit for prevention services, and the Chickasaw Caring Van, a 

partnership with Bluecross® Blueshield® of Oklahoma. The mobile unit services are an initiative 

lead by public health nurses. Additional initiatives by CNDH include a farm safety event with

activities for kids who live on rural lands and work on farms. 

Ms. Willis, Strategic Prevention Data Analyst at Chickasaw Nation, explained that public health 

data is limited in Chickasaw Nation. She stated that the Strategic Prevention Tribal Grant is a

successful partnership built on the SPLIT (structure, process, language, identity and technology)

framework. She informed the audience the “Define Your Direction,” a media campaign led by 

herself that has been implemented and running for the last year. “Define Your Direction” is a 

media campaign that reaches over 3,000 people with one message. The social media campaign 

posts about services and tools in Chickasaw Nation of which citizens are unaware. All activities 

are community and youth driven, such as a zombie chase and a safe-all-night event after a local 

high school’s prom. In addition, students who participated in the activities led by the campaign 

designed a mural displaying the logo and phrase of the campaign to show their support and 

appreciation. She concluded by stating “Define Your Direction” has won multiple advertising 

awards and continues to gain recognition for its contributions to the community. 

Councilman Antone took the floor next to ask the panel members a few questions. He asked if 

any public laws exist in the Chickasaw Nation court system that developed because of their 

multiple collaborations for the “Define Your Campaign” campaign. 

Mr. Saunkeah answered by stating that the Chickasaw Nation legal department will be 

presenting at 3:00 PM and can answer questions as they are involved in stakeholder groups. 

Panel members played their award-winning “Define Your Direction” video. 

Councilwoman Carlyle responded by stating that she is very impressed with the work and 

message of the campaign. She stated that the video sends a message in a “strong but simple 

way.”

Councilman Antone concluded the session and invited the next panel members to present on 

cultural practices and mental health prevention. 
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Cultural Practices That Inform Mental Health Prevention Programs

Panel participants 

• Shannon Dial, PhD, LMFT, Executive Officer, Integrated Services Division, Department of 

Family Services, CNDH

• Kelly M. Roberts, PhD, LMFT, Family Initiatives Advisor, Department of Family Services, 

CNDH

Panelists presented on Chickasaw Nation’s clinical research and the impact of cultural 

connectedness on health outcomes. Presenters shared the Chickasaw Nation’s work to 

integrate behavioral health services to create a system-wide approach to their Zero Suicide 

Initiative, domestic violence programs, and opioid abuse. 

Dr. Dial stated that to reach persons with behavioral health needs effectively, it was critical for 

Chickasaw Nation to think outside the box. The Chickasaw Nation determined the most 

effective way to reach tribal members with behavioral health services was by developing and 

implementing an integrated behavioral health system. By embedding behavioral health 

providers into general clinics and emergency rooms, Chickasaw Nation was able to increase the 

reach and impact of behavioral health services dramatically. Chickasaw Nation required all staff 

to look at mental and behavioral health in a new way, gaining a true biopsychosocial 

perspective. The approach resulted in a 152% increase in access to behavioral health care in

three years. Before integration, the system had approximately 400 behavioral health patient 

encounters per month; now it averages closer to 1,100.

Dr. Dial presented the Zero Suicide as an example. When the Zero Suicide challenge came to 

Chickasaw Nation, the team considered how it could reach the program goal inside of its

integrated care system. Zero Suicide is a project of the Education Development Center’s Suicide 

Prevention Resource Center. It is a key concept of the 2012 National Strategy for Suicide 

Prevention. Zero Suicide believes that suicides in persons receiving care through a health 

system are preventable. 

Chickasaw Nation began by implementing the Zero Suicide strategies in its emergency rooms, 

where they serve approximately 4,500 patients per month. They also standardized their

depression screening process. Chickasaw Nation leaders soon realized the screening concept 

could be carried throughout the entire health care system, being performed at every point of 

system entry, including dental services. To date, they have screened 71,000 persons, and 275 

have been identified at moderate to high risk for suicide. They immediately connected high-risk

individuals to appropriate services. From the point of identification, Chickasaw Nation routinely 

monitors these patients until their treatment is complete. Chickasaw Nation hopes this work 

enables them to never lose another tribal member.
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Dr. Dial emphasized that other tribal health systems can easily replicate screening across their

entire systems. Included in this same work has been an approach to address opioid addiction. 

Chickasaw Nation is beginning to talk through unique challenges that the opioid epidemic 

presents, including that the issue exists not just in the patient population base but in its

employee base as well. 

Dr. Roberts shared violence prevention activities and these notes from Chickasaw Nation 

leaders:

• Chickasaw Nation has a 24-hour on-call service and is ready to respond.

• Chickasaw Nation collaborates closely with its medical team through its protocols; 

coordination is strong and solid.

• A new facility is under construction; it will quadruple the space for shelter services.

• Regarding violence prevention, the domestic violence nurse examiner and sexual assault 

examiner roles are distinct; the certification and follow up are different. Chickasaw 

Nation is also exploring the distinction from elder abuse.

• Domestic violence nurse examiners address all intimate partner assaults in all Chickasaw 

Nation clinics, including strangulation for which there has been a demonstrative uptick. 

Examiners encourage patients to have a medical screening and hospital monitoring after 

such an event.

• Chickasaw Nation reviews each case to identify any process that can be improved to 

address and implement trauma-informed care more comprehensively.

Dr. Roberts shared that the interdisciplinary group working on violence includes police, 

chaplains, nurses, and social service workers. All of these professionals train continuously to 

increase their knowledge and skills around trauma-informed care.

Dr. Roberts expressed the critical importance of reflecting the Chickasaw Nation culture in the 

care environment, and how extending the culture through all services has increased patient 

wellbeing. As an example, she described a process they began two years ago to explore how 

culture could be incorporated in therapy protocols throughout the system of care. For context, 

she first defined historical trauma as “trauma passed on through generations.” In their process, 

Chickasaw Nation considered how to include elements of culture in their treatment plans to 

enhance identity, cohesiveness, and awareness. For context, Dr. Roberts shared that 

enculturation is “reintroducing people to their first culture.” They explored an AI Enculturation 

Scale that was created about ten years ago. It was tested in a variety of ways with several 

populations and had significant outcomes. In a pilot study, Chickasaw Nation determined that 

the AI Enculturation Scale was too pan-Indian and too generic to resonate with Chickasaw 

people. So, the Chickasaw Nation elders met with the Chickasaw Nation cultural department 

and identified 38 items that should appear in a Chickasaw Nation Enculturation Scale. The 
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Chickasaw Nation Institutional Review Board (IRB) further refined and strengthened the tool. 

Eventually the Chickasaw Nation health clinics tested it and determined that it is valid and 

reliable. The tool includes three primary measures: Satisfied Subscale; Identity Subscale; and 

Enculturation Subscale. In the pilot test, all subscales were above 0.8 with a variance of 0.61. 

Two hundred fifty Chickasaw Nation members filled out the instrument in the preliminary test 

phase. Chickasaw Nation will now use the instrument to measure the impact of its efforts to

incorporate a sense of identity and cohesion into wellness plans. 

At this conclusion, Councilman Antone opened the floor to the TAC delegates, and invited CDC 

senior leaders and other tribal nation leaders to sit at the table for questions and answers.

Chairwoman Andrews-Maltais commented on the “extraordinary achievement” of this effort. 

She was excited to see the pilot outcomes, and recounted that she often sees that the lack of a 

“cultural rudder” limits the recovery of AI/ANs from incarceration and drug addiction. 

Dr. Montero congratulated the doctors on the “amazing work.” He stated that before working 

at CDC he was not able to get his organization to a 100% depression screening at all points of 

entry. He asked the panelists about the organizational capacity to manage the demand that is 

generated from the screenings.

Dr. Dial confirmed that their success always drives a demand for more behavioral health 

workers to meet the identified need. By screening everybody, there is an identifiable 

subpopulation of the most severe cases. These cases create the highest demand on staff time. 

Those persons who screen in the low-risk category are simply monitored when they see their 

primary care provider. The integrated visits reflect a low effort base-style interaction. All of the

behavioral health providers now see 10–16 patients a day, as opposed to previously seeing only

6. Right now, Chickasaw Nation has great communication between our providers and patients. 

The nurses do the actual screenings in the nurse triage. If the electronic screening score 

warrants the behavioral health team’s intervention, it will trigger an encounter in the clinic.

Dr. Roberts stated that learning clinical patterns has been key to maximize capacity. For 

example, the data from clinics reveals that every 8 hours there will be a blip on the dental 

radar. In addition, it was important to learn the best communication channels to make the 

team more efficient. For example, the behavioral health team uses a text message system. Dr. 

Dial also asserted that integrated care is made or broken based upon the staff that is hired. 

Certain personality traits and high confidence in the behavioral health clinician are critical. 

Councilman Antone thanked all panel members. He noted that culture is a protective 

component of mental health and wellbeing. He stated that cultural practice is not pan-Indian 

and that the strength of native people is in their unique historical and cultural identities. All 
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tribes need to understand what Chickasaw Nation has presented as a model. He applauded 

Chickasaw Nation for finding the power to make their people stronger and more resilient. With 

this comment, he concluded the session. 

Tribal Health Policy and Law Interventions

Panel participants 

• Debra Gee, JD, (Navajo Nation), General Counsel and Executive Officer, Legal Division, 

Chickasaw Nation

• Carolyn Romberg, JD, Director/Deputy General Counsel, Legal Division, Chickasaw 

Nation

• Kym Cravatt, JD, MPH, (Seminole/Muscogee/Creek/Chickasaw), Assistant General 

Counsel, Legal Division, Chickasaw Nation

This session explored the legal framework of tribal sovereignty and how tribes engage with 

other health law partners while maintaining their tribal sovereignty. 

Ms. Gee introduced the session by defining sovereignty as the inherent right to govern. Within 

the context of tribal sovereignty, the issue of jurisdiction is often the greatest challenge for the 

Cherokee Nation Legal Division to address. The organizational structure of tribes in Oklahoma 

makes jurisdictional determinations very challenging. In regards to health care, Oklahoma has 

some tribes operating their own care in part or in full under the Indian Self-Determination and 

Educational Assistance Act (Public Health Law 93-638). While other tribes continue to receive 

care provided directly through IHS using PH Law 93-638, Cherokee Nation contracted with IHS

to open a seventy bed medical facility in Ada, Oklahoma in 2010. 

Ms. Gee explained that Cherokee Nation has created a tribal framework to address tribal health 

issues. Law, policy, and legal intervention and regulation all play a role in the structure of the 

tribal health system. She stated that there might be a US Code, a tribal code, a state statute, 

and a policy (defined as a set of principles established by a system or a body to determine 

future direction) and that all of these may have authority and influence over the same health 

issue. In addition, there may also be regulations (federal, industry, or other) that define how 

issues are addressed. Each of the different concepts intersect and interplay. It is the 

responsibility of the Cherokee Nation legal counselors to review carefully and to discern what 

does or does not apply. Ms. Gee concluded by stating that the legal division delves deeply into 

the gray areas of these factors and explores the risks associated with each desired course of 

action in order to advise the Cherokee Nation leadership.

Ms. Cravatt presented a few examples of Tribal Health Law and Policy Interventions that have 

affected tribes including Chickasaw Nation. These included Tribal food safety where 53 tribes 
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have adopted food safety codes. Chickasaw Nation along with many other tribes have adopted 

the Food and Drug Administration’s food safety code. Another area that frames decisionmaking is the IRB. Chickasaw Nation has an IRB with a set of policies that frame the scope and 

type of research that can be conducted on Chickasaw people. Proposed research must be 

carefully reviewed and adjusted to be in compliance with these policies in addition to other 

influencing laws and regulations. A special area of interest in the current state of health is the 

use of policy and law to address the opioid epidemic. Ms. Cravatt reported that the state of 

Oklahoma ranks in the top 5 of states for opioid prescribing rates and the top 10 for high-dose 

opioid prescriptions. In Chickasaw Nation, three counties rank among the top 5 in the state for 

unintentional poisoning deaths and AI/ANs living in the Chickasaw Nation reported a 

statistically significant higher rate of prescribed opioid misuse when compared with nonnatives. Garnering recent national attention was the court case of Cherokee Nation vs. 

McKesson Corporation, et al. filed in the District Court of Cherokee Nation this April. This case 

was featured on many national new outlets. Ms. Cravatt concluded her section by stating that 

the assertion by Cherokee Nation was that the defendants had the ability to reduce the 

diversion of opioids but chose not to. 

Ms. Romberg presented on mental health and law stating that the Oklahoma court system 

created a unique set of specialty courts termed “drug courts” for offenders in recognition of the 

close connection between illicit drug use and mental health issues. This model developed by 

the state’s department of justice allows local jurisdictions, like Chickasaw Nation and other 

community partners, to collaborate with the court to provide services to Chickasaw people 

facing a drug charge. It has been found to be a good partnership. Ms. Romberg shared that the 

current law allows for Emergency Detention/Civil Commitment, a 72-hour involuntary 

commitment if an individual poses a danger to him or herself or others. In the case of 

Chickasaw Nation, when an individual is taken from trust property and placed in a state health 

facility the nation loses jurisdictional authority. Therefore, it is in the nation’s best interest to 

work closely with the court system to ensure important mental health resources are available 

at sentencing. The ultimate goal of Chickasaw Nation is to have its own mental health court 

system because the problem is not going to go away. Chickasaw Nation health services securing 

hospital admissions for Chickasaw people caught in the court system has been far easier to 

accomplish. This work is carried out under executive directives from the Chickasaw Nation’s 

governor. Ms. Romberg concluded by stating that the policies and procedures have been 

adopted to support this direction as legal codes can be far more difficult and time consuming to 

change. 

In closing, the panelists shared with CDC that the Cherokee Nation Legal Division also reviews

grant opportunities. When tribes are treated like states within the context of a funding 

opportunity it makes it very challenging to compete successfully. The nation advises that this be 

kept in mind as the agency develops future NOFOs.
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Councilman Antone opened the session for comments and questions.

Councilwoman Carlyle stated that in the Ak-Chin Indian Community, there are too few pain 

management doctors and it is, therefore, too easy to hop from doctor to doctor to support an 

addiction. The physicians are also unable to view the records of outside prescribing. With a 

dramatic lack of professional care and expertise to follow up with patients who are prescribed 

narcotic medications for pain, the severity of the opioid abuse issue continues to grow.

Ms. Romberg responded that Oklahoma does have a prescription drug monitoring system 

(PDMS) and that both providers and pharmacists can review prescribing records in this system. 

In addition, Chickasaw Nation employs a pain management contract within its clinics to support 

the pain management policy. This allows the doctors prescribing narcotics to hold patients 

accountable for compliance. If violated, the physician will no longer prescribe narcotics to that 

patient. 

Councilwoman Carlyle asked the panel if they had any experience around “medical marijuana 

cards”. Panelists responded that they have a zero tolerance policy regarding marijuana. 

Patients living in tribal housing submit to random drug testing. In the one case where a screen 

came back positive for a resident with a medical marijuana card, much dialogue ensued as an 

effort to assure that the resident’s housing and job were not threatened. Ms. Romberg shared 

that Oklahoma has not adopted a medical marijuana statute nor a recreational use statute. 

Councilman Chester Antone concluded the session. 

Adjourn

Councilman Antone adjourned the meeting.
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WEDNESDAY, AUGUST 9, 2017

Opening Blessing and Reminders 

Members present for roll call:

• Alaska Area Delegate—President Alicia Andrew, Karluk IRA Tribal Council

• Bemidji Area Delegate—Representative Robert TwoBears, Ho-Chunk Nation of 

Wisconsin

• Great Plains Area Delegate—Chairman Robert Flying Hawk, Yankton Sioux Tribe

• Navajo Area Delegate—Vice President Jonathan Nez, Navajo Nation

• Oklahoma Area Authorized Representative—Lt. Governor Jefferson Keel, Chickasaw 

Nation

• Phoenix Area Delegate—Councilwoman Delia Carlyle, Ak-Chin Indian Community

• Portland Area Delegate—Council Member Travis Brockie, Lummi Nation

• Tucson Area Delegate—Councilman Chester Antone, Tohono O’odham Nation

• Tribes-at-Large Delegate—President George Edwardson, Inupiat Community of the 

Arctic Slope

• Tribes-at-Large Delegate—Tribal Employee Byron Larson, Northern Cheyenne Tribe

• Tribes-at-Large Delegate—Tribal Councilor Bryan Warner, Cherokee Nation

[Quorum Met] 

Members absent:

• Tribes-at-Large Delegate—Board Member Darcy Morrow, Sault Ste. Marie Tribe of 

Chippewa Indians

Delegate vacancies: Albuquerque, California, and Nashville Areas 

Tribal Public Health Accreditation Panel

Presenter

• Lisa Pivec, MS, Senior Director of Public Health, Cherokee Nation

Ms. Pivec began by thanking Lt. Governor Keel for hosting the TAC meeting and by giving thanks 

to Chickasaw Nation. She acknowledged her staff for their efforts. 

Ms. Pivec stated that Cherokee Nation is fortunate to have been working closely with the 

Chickasaw Nation, Choctaw Nation, and the Muscogee (Creek) Nation. Ms. Pivec and her staff 

pledged that they would help other tribes get accredited after they became accredited. She

believes that if every tribe in Oklahoma becomes accredited they can make a big difference in 

the health of people of Oklahoma, which is currently ranked 48 in several health issues. 
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She explained that one lesson she has learned over the last year is that public health 

professionals do not tell their stories. They do not talk about who they are as people and why 

they are so passionate about what they are doing. As an early step, Cherokee Nation defined 

public health for themselves, including what it means to Cherokee people. Namely, that they 

take care of people collectively—mind, body, and spirit. 

Ms. Pivec presented a brief overview of Cherokee Nation:

• Cherokee Nation is multi-jurisdictional; it has 14 counties and a tribal jurisdictional 

service area spanning 9,200 square miles

• Cherokee Nation is home to more than 315,000 citizens

• 210,000 Cherokee Nation members live in Oklahoma

• 140,000 reside in a tribal jurisdictional service area

• There is a Tribal Public Health Advisory Committee to the Oklahoma State Health 

Department of Health , and they have a great relationship

She went on to describe her view that direct care is part of public health, and that when people 

walk through the doors of her facilities they should walk out healthier. 

When she and her staff began the accreditation process, they began by reviewing the 

standards, deciding what they meant to them, and how they compared to others. She 

illustrated this by sharing a strategy map that can be used to assess community health status. 

Each box on the map has a Public Health Accreditation Board (PHAB) domain. She and her team 

determined what each domain means to Cherokee Nation. They also assessed who already had

capacity for different activities, which helped identify potential partnerships, and what 

Cherokee Nation needs to build themselves. 

She pointed out that tribes will never have enough direct care dollars, and that they need to 

start focusing on healthier communities. She shared that it is important to make the healthy 

choice the easy choice. 

Ms. Pivec presented a timeline describing their accreditation process:

• 2007 – began exploring upcoming accreditation

• 2009–2010 – participated in PHAB beta test, which helped them to be successful in the 

application

• 2011 – received National Public Health Improvement Initiative (NPHII) funding of $800K 

for 4 years; it didn’t completely fund their work, but did help

• 2012 – completed the National Public Health Performance Standards Program

• 2013 – applied for accreditation

o NPHII funding covered the $25,000 cost to apply for accreditation

• Nov 2014 – uploaded all documents

• Oct 2015 – hosted a site visit with the PHAB team
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• Aug 2017 – received PH accreditation; Cherokee Nation is the first tribe to receive PH 

accreditation

Ms. Pivec described that tribal public health systems are diverse and unique, and linked closely 

to direct care. She believes tribes have the perfect system to assess how public health and 

health care can intersect. 

Using the accreditation template, Ms. Pivec and her staff identified potential partnerships with 

state and local organizations. She emphasized that it is important to leverage capacity where it 

already exists. For example, it is more efficient and effective to partner with an existing public 

health lab than to create a new one at the tribal level. “Partnership is essential for the future of 

AI/AN health.”

Partners may include national organizations, other tribes, clinical providers, state and local 

health departments, and communities—including both communities of interest and 

communities by location. Partnership is mutually beneficial; tribes have a lot to offer states, 

including a lot of people on the ground.

Some lessons learned include:

• Cherokee Nation does not have a public health code; they need to establish one

• Governance standards should be clearly outlined at the start, and should include who 

the governing body is, and how information flows

• Performance management/quality improvement needs to show how that clinical health 

piece works with public health

• Prepare Memorandum of Understanding (MOU) templates for services a tribe needs 

from the state

• Pay attention to the prerequisite documents, as they are an important foundation

For next steps, Ms. Pivec and her staff are developing a conceptual map for organizational 

design, and are still struggling to implement what they have documented. They will put it into 

an organizational design they can implement practically in their health system. They want it to 

be something that other tribes can use too.

She emphasized that community engagement is the primary driver for the design, and that it is

important to talk to the people living in communities. They have seen great outcomes when 

community coalitions take ownership and action. She also pointed out that sustainability is 

needed, and that they need to determine how to continuously dedicate a piece of their budget 

so they are not reliant on grants. Internal (within the tribe and tribal public health department) 

and external (with other tribes) mentorship is also important. 

Ms. Pivec also pointed out that it will take leadership to make accreditation happen, along with 

political courage on behalf of all the leaders around the table. In addition, it will require 

education of community members and decision makers about what public health is. For 
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example, some decision makers have told her they will take care of public health once all the 

health care needs are met. Accreditation is a shift in thinking, requiring approaches such as job 

sharing, inclusion—a shift from clinical to community, embracing what is good now, and 

creative financing. She said it is no longer “optional.”

She concluded that tribal public health infrastructure needs to be a priority. Tribes need people 

to do the work (through workforce capacity and technical assistance), consistent funding 

mechanisms and to be eligible for NOFOs, and access to successful state models. Ms. Pivec

illustrated the impact of community health infrastructure by sharing that her own mother has 

suffered a stroke and has dementia. Her health is affected by her zip code, and we need to 

build healthy communities for all. 

Mr. Warner thanked the Cherokee Nation and reiterated that sustainability can only come with 

strong infrastructure funding for all of the tribes. Cherokee has a group that is paving the way. 

To be sustainable, any type of funding tribes get has to support infrastructure. 

Councilman Antone added that on a recent call, when he asked about public health 

accreditation, Cherokee Nation mentioned they had multiple counties and that it would be 

easier with fewer counties. He asked Ms. Pivec to elaborate.

Ms. Pivec responded that with fewer counties there will be fewer cross-jurisdictional issues. For 

Councilman Antone’s area, she said the state partnership will be important. There will be some 

measures/domains that his tribe would not need to develop since they could get them through 

collaboration and partnership.

She suggested looking at the conceptual map to identify what his tribe already does, what they 

could partner to access, and what they’d need to build. She emphasized that if they can get a 

public health code passed that would be key. PHAB can help with that—it would have helped 

Cherokee Nation a lot. 

Councilman Antone commented that his tribe may already be close, but they have not assessed 

it, and that it would be the key to get forward movement. They are also large enough and have 

done things with counties around them. They may be further ahead of the game than they 

think.

Dr. Montero congratulated Ms. Pivec and agreed that technical assistance is an important tool. 

He mentioned there is ASI funding available via NIHB. Applications are due September 1. He 

encouraged meeting participants to get in touch with CDC if they need help. 

Lt. Governor Jefferson Keel also thanked Ms. Pivec, and discussed the need for creative 

financing. There are tribes that are interested; some are already doing many of the things 

mentioned, but without sufficient funding some do not see why they should do it. He 

encouraged her to reach out to other tribes, or present at the NIHB conference so she can 

provide an example. This is particularly important for remote tribes that do not have access to 

clinics; if they can develop a collaboration with state and local authorities that would help. 
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There is a creative way to get funding to these programs, whether it is for infrastructure for this 

or for other programs. 

President Andrew added that she represents Alaska, but is from a small community. Every 

person matters. For years, her area has been fighting to get the support need for their people. 

Although Alaska has come a long way with a consortium, politics is still the hardest part. They 

want what is best for their people, who often fall through the cracks. 

Ms. Pivec stated that it is important to educate their own citizens on trust responsibility and 

what it means to be a tribal citizen, how to advocate, and what they can do.

Councilman Antone concluded the session. 

Empowered Living – A Chickasaw Nation Youth Wellness Clinic 

Panel participants

• Neilsson Rais, MD Pediatric Medicine Specialist and General Practitioner, Chickasaw 

Nation Medical Center, CNDH

• Jeffrey Wells, PT, DPT (Chickasaw Nation), Outpatient Physical Therapist, Ardmore 

Health Clinic, CNDH

• Ashley Weedn, MD MPH, FAAP, Assistant Professor, General and Community Pediatrics, 

University of Oklahoma Health Sciences Center; Medical Director, Healthy Futures, 

University of Oklahoma

• Stephen Gillaspy, PhD, Associate Professor, General and Community Pediatrics, 

University of Oklahoma Health Sciences Center

• Sheryl Goodson, MBA, Executive Officer of Satellite Clinics, CNDH

• Bobby Saunkeah, RN, MSGCE, CIP (Kiowa Tribe), Manager, Research and Population 

Health Division, CNDH

This session addressed pediatric obesity through the Chickasaw Nation’s multi-disciplinary 

behavioral modification clinic. It highlighted the collaboration with Chickasaw Nation’s public 

health teams, including a research component and an external collaboration with Oklahoma 

University Children’s Hospital. 

Mr. Saunkeah, provided the background for the presentation explaining that the clinic concept 

formed out of the relationship between clinical and public health work on the health issue of 

obesity. Epidemiological data from FY 2016 shows that Chickasaw Nation has high rates of 

obesity starting in childhood and progressing through adulthood. Chickasaw Nation identified 

that pediatric obesity was a top health priority for making impactful population health change. 

The clinic focuses on wellness behaviors, including behavioral modification with goal setting 

rather than just weight control and monitoring. Children are referred along with a responsible 

adult to the Empowered Living Clinic and a comprehensive first appointment is scheduled. Each 

person referred spends one hour with each provider on the Empowered Living team. Once 
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these sessions are completed, the team meets to discuss the information they have gathered 

and develop a plan of care for the child. From this point forward, the child’s progress is 

monitored every two weeks. Each provider on the team works with the patient and his or her 

family on setting a specific goal. All factors that contribute to obesity in children such as sleep 

patterns, physical activity, and relationship building are considered. The clinic focuses on 

creating healthy habits with a slow introduction of the new behavior, followed by affirmations 

as each goal is reached and new goals are set. In April 2017, the clinic hosted an “Empowered 

Living Garden Party” to help clinic participants enjoy the process of growing and preparing 

healthy foods.

Dr. Rais stated that he serves as the team pediatrician. He reported that prior to his work in the 

Empowered Living Clinic, he understood there was a need for intervention that adequately 

addressed pediatric obesity as he was seeing a vast array of comorbidities in children directly 

linked to their weight. Only seeing the child in a medical appointment limited his ability to 

influence the change required. Comorbidities in children can be hard to identify as children 

often compensate so well that there are no outward signs of disease. Instead, disease is 

detected via clinical examination and mostly through laboratory test findings (i.e. 

hyperlipidemia, insulin resistance, elevated blood sugar). The children rarely understand their 

own mortality, but their parents do. Thus, it is incumbent upon health care providers to engage 

the parent in order to experience the greatest success in addressing pediatric obesity. At the 

Empowered Living Clinic, the goal is to show families how small changes can make a big 

difference in these complicated diagnostic measures that they may struggle to understand. 

Mr. Wells emphasized that this approach is “wildly unique,” although they have collaborated 

with Healthy Futures, a non-profit organization dedicated to supporting positive youth 

development. He stated that this multi-factorial approach is the only way to address fully the 

intricacies of childhood obesity. He explained that children tend to reach for what is convenient 

and easy to eat, while parents buy what is affordable when under financial duress. The 

Empowered Living Clinic’s behavioral health counselor is integral to addressing such challenges. 

In addition, they assist with the anxiety and depression that frequently occur while battling 

obesity. Mr. Wells stated that the role of the physical therapist is to rule out musculoskeletal 

issues and to identify any limitations that may impede a patient’s ability to obtain their physical 

activity goals. Once this review is complete, a plan is developed to support the patient in 

obtaining his or her self-identified targets. A benefit to the interactions with various clinicians 

on the team is that it provides children an opportunity to build a genuine connection with at 

least one provider. Often these trust relationships become integral to promoting changes in the 

patients behavior. 

The clinic uses a behavioral modification technique based upon motivational interviewing,

which is patient-centered and challenges the negative thought processes and beliefs held by 

the patient by focusing instead on the patient’s wants and needs. The clinical team serves as a 

sort of navigation system giving the patient guidance on where they want to go through finely 
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tuned adjustments and small changes. The clinical team addresses many common challenges 

seen among pediatric patients, such as no desire by the child to change or the parents refusing 

to change along with the child, which creates lack of modeling behavior in the child’s support 

environment. The clinical team serves as one of the support environment role models by 

participating in activities with the children from 5Ks to gardening to healthy cooking. 

Dr. Rais affirmed that it is important to weave the clinical team into the life of the pediatric 

patient. In so doing, the team creates a relationship in which the child feels as though he or she 

can rely fully on the team, which creates a community of support. 

Mr. Wells emphasized that the clinic strives to foster a compassionate environment. He 

concluded by stating that the program does not focus on just the weight management but 

rather the entire environment which causes one to gain weight. 

Dr. Weedn stated that the model for the program came from the expert pediatric committee 

on obesity, which includes CDC, the Health Resources and Services Administration, and the 

American Medical Association. Ten years ago, the guidelines were used to build a staged model 

for weight management were addressed. For reference, stage 1 (primary care) and stage 2

(allied health) were separated from each other because that is how they operate inside the 

health care system. The model sought to take primary care engagement and allied health care 

engagement and reach stage 3 (multidisciplinary care program). In 2012, the Oklahoma 

University Health Science Center developed and implemented the model in Oklahoma and 

began to study its impacts. In 2014, a registry was developed where every academic center or 

community team could report its data. Looking back over five years, the biggest outcomes that 

have changed are laboratory values (done every 6 months). These changes are connected to 

the activities and changed behaviors of the patient and are further linked to future health 

impacts. 

Dr. Weedn stated that intriguingly, there is a decrease in body mass index (BMI), a finding often 

ignored. For the pediatric population, the observed change is instead in weight gain velocity as 

opposed to weight loss significant enough to create BMI change in children. The laboratory

values represent the changes.” As the pediatric patients move from abnormal to normal 

laboratory values their future health risks decrease substantially. From a research perspective, 

the next steps are to begin the Empowered Living Registry Evaluation. Since the Empowered 

Living Clinic is a closed system, it is possible to explore the additional family impacts of the clinic 

rather than just the effect on the pediatric patient. Chickasaw Nation is the only community 

based multidisciplinary team, all other teams are academic institutions, further making this 

clinic design a unique opportunity to evaluate. Dr. Weedn concluded by stating that at the 

Empowered Living Clinic, when a goal is set by the child, each family member supporting that 

child commits to this change as well (e.g., removal of sugary drinks from the home). 
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Dr. Gillaspy, noted that the clinic itself is the “clinical intervention” for the patient but serves as 

“early intervention” for the rest of the family members. Due to the closed electronic medical 

record system, the ability to track the family member impacts exists. 

Mr. Saunkeah, shared that Chickasaw Nation is developing a biorepository as part of the 

Empowered Living Clinic with infrastructure currently in the planning phase of development. 

Another research component is the health messaging consistency within the health system. 

Anecdotally, patients in the health system are getting different messaging. Chickasaw Nation 

wants to assess the validity of this claim in order to develop and implement consistent health 

messaging regarding obesity across all areas of care within its health system. 

Lt. Governor Keel thanked the group for the presentation. He also shared that the inclusion of 

the registered dietician in the team is valuable as there are native communities across the 

country who depend on the commodity distribution. It is critical to assist them in the healthy 

ways to prepare these challenging foods.

Ms. Goodson shared a story of a patient who had cleaned out all unhealthy food from the 

home’s cabinets, but did not know how to move forward. The team stepped in to provide 

critical education on how to shop, what to buy, and how to cook and prepare healthy foods. For 

the younger generation who may not cook and therefore may rely upon fast food services and 

convenience store foods, the clinical team works to help them improve selections from among 

these items. 

Dr. Rais added that the clinic also creates “Get Fresh” videos that help to do some of this 

important re-education. Currently, this pilot program of the clinic is operational only one half 

day each week. 

Mr. Wells shared that while “food cabinet cleaning” is great to start, the issue occurs when the 

“diet” mentality fades away. People resort back to old habits that may not be conducive to 

sustaining their weight loss. Hence, the real change is in helping change behavior. Mr. Wells 

concluded by stating that is why Empowered Living Clinic teaches and educates other on 

healthy behavior, so that they are not just giving instruction but are also showing clients how to 

live a tangibly healthy lifestyle.

Ms. Goodson wanted to stress the research component of the clinic stating that Chickasaw 

Nation has developed funding relationships with Oklahoma University Health Sciences Center 

and the State of Oklahoma. What they need most is a full-time clinic coordinator with 

exceptional health-coaching skills, as there is a high degree of patient interaction. She 

emphasized that there is a vast amount of work that could be done if there is appropriate 

funding.

Dr. Montero posed a question to the panel stating that it is known that excellence in clinical 

management of obesity is required. He stated that in their presentation, it was mentioned that 

consistency in messaging is an area for improvement in the health system. He asked the panel 
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how they address the cultural needs in the prevention arm when health behaviors may be 

culturally specific.

Dr. Weedn responded that development of cultural messaging is tribally specific and would 

need to occur at the tribal level rather than the state level. She relayed that the university’s 

pilot data regarding health messaging was observed among mothers of young Native American 

children. In this specific group, there were differences in opinion on how to prepare foods. 

Mr. Saunkeah responded that the program just received IRB approval last month to begin the 

research piece within the program. Every component has the Chickasaw culture embedded in 

it. Consent forms for participants are being finalized now and an application for an Empowered 

Communities grant with the Office on Minority Health will be submitted. It is anticipated that 

next year Chickasaw Nation will have data to share.

With this final response, Councilman Chester Antone concluded the session.

Tribal Epidemiology, Data, and Research 

Panel participants 

• Michael Peercy, MPH, MT(ASCP)H, Epidemiologist/Biostatistician, IRB Administrator, 

Division of Research and Population Health, CNDH

• Bobby Saunkeah, RN, MSGCE, CIP (Kiowa Tribe), Manager, Research and Population 

Health Division, CNDH

This session highlighted issues such as disease surveillance, data protection, and research 

partnerships. 

After introducing himself and his colleagues, Mr. Peercy shared that Chickasaw Nation Division 

of Research and Population Health staff focus on the surveillance of chronic disease, infectious 

disease, emerging pathogens, community health assessments, outbreaks, and more. The 

division employs many tools to explore community health, including geographic information 

system mapping. In an outbreak response, the division frequently encounters complex 

jurisdictional issues and must work to ensure all appropriate response actions occur within 

these restrictions. For example, to surveil influenza outbreaks, the division must work with 

regional and local health departments to procure the vaccine, distribute and administer it to 

Chickasaw community members. 

Research is also a large part of the division’s work, and all of the work requires a high degree of 

partnership engagement. Mr. Peercy reported that most recently, his division has been 

converting their Resource Patient Management System (RPMS), used for the Chickasaw 

healthcare system, to a more friendly database that can interface with statistical software to 

perform better data analytics. For example, when a baby is born, it is assigned a new medical 

record number in RPMS and is immediately de-linked from its mother’s electronic record. The 

Chickasaw Nation has identified twelve key data components in the RPMS system that can be 
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used to re-link the charts and allow for the longitudinal examination of patient data. Mr. Peercy 

affirmed that in the tribal world it is very hard to separate clinical from public health. Therefore, 

he and his staff look at patients as groups, or “panels,” and they work closely with their clinic

infection control offices to provide sentinel alerts on issues in their population.

Mr. Peercy explained slides the depicted Chickasaw Nation statistical data that had been linked 

and corrected, including death rates by cause. He paused on the slide showing “Cancer Death 

Rates 2010–2015 for Chickasaw Nation Counties - American Indian Population.” He shared that 

the data is derived from Oklahoma State’s Department of Vital Statistics and that the Chickasaw 

Nation has developed a new cancer registry. Providers have reported that there is a high rate of 

late-stage cancer diagnosis in Native Americans due to lack of routine screening. 

Mr. Peercy also highlighted on the slide “Years of Potential Life Lost” that motor vehicle 

accidents remain the number one cause of death for the nation, while a new number two cause 

has emerged—from 2010–2015, accidental opioid poisonings jumped to this position. 

Accidental poisoning was not even in Chickasaw Nation’s top five two years ago. 

Chickasaw Nation is starting to see a small decline in tobacco use rates, but overall these rates 

are still very high and are reflective of the high rate of lung cancer observed on the “Cancer 

Death Rate” slide shown earlier in his presentation. He added that they derived tobacco use 

rates from clinical data, which tribes frequently use as a proxy, since public health data are 

often not available.

Mr. Saunkeah described the Chickasaw Nation IRB stating that IRBs are designed to protect 

human research subjects from harm during the research process. The Chickasaw Nation has 

had an IRB since 1998. Tribal IRBs came about due to historical abuses regarding research with 

tribes, and the reluctance many tribes had to participate in research due to these abuses. When 

done correctly, research is a great opportunity for tribal people and nations; it can help

increase and expand services when done in a culturally appropriate way. The difference 

between an academic and tribal IRB is that a tribal IRB is charged not only with protecting the 

individual, but also the tribe as a whole. The Chickasaw Nation IRB reviews all publications 

without exception. The tribal IRB maintains partnerships that are respectful with academia but 

does have differing responsibilities in the actual IRB process.

Mr. Peercy discussed “data sovereignty,” (i.e., data ownership) as it applies to tribes, stating 

that it is the right to govern the collection, use, and storage of its own data . As with most 

tribes, the Chickasaw Nation does not allow for research data transfer or secondary analysis 

without tribal approval. Chickasaw Nation supports meaningful sharing with its partners, but 

emphasizes that the tribe retains total control over the “how, when, who, and disposal of”

data. Through epidemiology and research many data are created, so the division operates very 

conscientiously, spending a great deal of time to build trusting relationships with partners. The 

division has ability and skill to do many important public health data analytics, but could always 

use more capacity. The state health department employs epidemiologists across all of their 
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sections; tribes may not have an epidemiologist at all, or at best may have one who must take 

his or her skills and evolve into a “jack of all ‘epi’ trades.” 

Mr. Saunkeah shared that strongly written guidelines that are shared upfront with all research 

partners have greatly helped their IRB. The nation’s research agreements all acknowledge data 

sovereignty. This transparency has been helpful in establishing trust and promoting research.

Councilman Antone asked about the essential components of an IRB. 

Mr. Peercy replied that for federal recognition, an IRB must have community involvement, 

directorship, and a mix of scientists and nonscientific members. A tribe can form a research 

review board without having a federally recognized IRB. This would route all research decisions 

to the council or other designated tribal group. Chickasaw Nation chose to have the federal 

registration, which does give more influence when engaged with academic institutions should a 

difference of opinion occur.President George Edwardson described research abuses within his 

tribe. Mr. Saunkeah responded that this example provides the context for why tribes are 

forming IRBs and exerting their sovereign authority to review all potential research. The tribal 

IRBs can prevent these abuses.

Representative TwoBears asked the panel if Chickasaw Nation provides insurance coverage for 

tribal members, and if so, if it shares information with the insurer.

Mr. Peercy replied that there is no close work with the insurance company, although there is 

effort to break down the barriers in the separate caches of data that the tribe owns. If able to 

do so, they could identify a greater economic impact of prevention activities through the 

sharing. 

Mr. Saunkeah also shared that the division strives to improve its external communications 

through newspapers and the website, and are exploring additional communication strategies 

through community focus groups and leadership presentations. Mr. Peercy stated that they 

share some of the more clinical projects within Grand Rounds, so that providers have the 

information as quickly as possible.

With no further questions, Councilman Antone concluded the session. 

Built Environment: FITWEL, Resources for Tribes 

Panel participants 

• Joel Kimmons, PhD, Health Scientist, Division of Nutrition, Physical Activity and Obesity, 

NCCDPHP, CDC 

• Giselle Sebag, MPH, LEED AP, FITWEL Ambassador, Healthy Places Programs Director. 

Center for Active Design, Strategic Planning and Partnerships Consultant, Equitable and

Sustainable Cities, Greater New York City Area
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Dr. Kimmons started the presentation by stating that “built environment” is a scientific theory 

around health behavior that aims to make a healthy lifestyle part of the environment, the 

infrastructure around you, and the opportunities it provides for healthy behavior. Dr. Kimmons

explained that at NCCDPHP, his division uses the Star Community Index as a strategic planning 

and performance management system. The system offers local governments a road map for 

improving community sustainability by focusing on initiatives that make a whole community 

healthy. He explained the connection between the environment and health behaviors by 

stating that a built environment aims to make a healthy lifestyle more accessible, affordable,

and sustainable. Built environment theory encompasses social structures, cultural norms, and 

personal values to change behavior by changing individual components. Dr. Kimmons defined 

“society” as a built environment that provides individuals with opportunities. Culture influences 

the choices we make because other members in our family make similar choices. The question 

built environment theory aims to answer is: how do we adjust society to make it supportive for 

health behaviors? He explained that behavioral choices are reactive and driven by sensory 

exposure, availability, cultural norms, and mindset. Analyzing how design affects behavior will 

facilitate impact on individual behavior. 

Ms. Sebag presented on FitwelSM—a certification system that incorporates behavioral design 

into buildings to promote healthy behavior. Ms. Sebag explained how atmosphere can affect 

the brain by providing the example that subluminal triggers can affect the vagus nerve and 

make someone irritable. She stated that Fitwel is a high-impact building certification that 

supports healthier workplace environments and improves occupant health and productivity. 

Fitwel is an independent non-profit organization in New York and is currently into its beta

phase in terms of product development. Fitwel is an effort lead by CDC and the General Services 

Administration. Ms. Sebag concluded by stating that Fitwel aims to create value in the 

marketplace around health.

Dr. Kimmons explained that CDC scientists have researched the link between built 

environments, physical activity, and buildings. Dr. Kimmons and his CDC colleagues spoke on 

health issues that are becoming an increasing priority for Fitwel.

 These priorities include 

chronic disease risk factors, mental health, social equality for vulnerable populations, 

occupational safety, and improvements in community health. Fitwel’s unique value lies in the 

fact that all strategies suggested by the certification program are voluntary and require no 

prerequisites strategies that could be cost-prohibitive. Dr. Kimmons explained the certification 

process, which has the following steps: 

• An organization’s staff registers and inputs information 

• A scoreboard is completed and a benchmark is received

• Verification documents are uploaded by staff

• Staff submits all documents and receives a Fitwel rating

Dr. Kimmons stated that as a part of built environment, food service operators ideally should 

provide a spectrum of food options that can create a healthy environment by default. A 
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component of built environment is rebuilding the worksite food environment to make healthy 

eating more accessible. Dr. Kimmons concluded by stating that federal, tribal, and state 

governments can work together to change the culture in terms of diet. Dr. Kimmons and Ms. 

Sebag concluded the session by giving a few more facts about the Fitwel program. Ms. Sebag 

explained that the program is a result of five years of rigorous empirical public health evidence 

analysis. Fitwel has been optimized for existing buildings and aims to strengthen the link 

between built environment and health outcomes. In conclusion, Dr. Kimmons and Ms. Sebag 

stated that the audience should take away the following two points:

• Organizations should have a food service contract that offers food products that fulfill 

basic human needs. 

• Organizations are encouraged to review their Fitwelscore card to determine if individual 

aspects can be incorporated in your office space that can encourage positive health 

outcomes. 

Councilman Chester Antone thanked the built environment panel members for their time and 

concluded the session. 

Association of American Indian Physicians

Panel participants 

• Jamie McDaniel, MS, Program Manager, Million Hearts: Hypertension Control 

Improvement in Indian Country, AAIP 

• Gary Lankford (Cherokee Nation): Program Director, Advances in Indian Health Care 

Student Programs, AAIP

Mr. Lankford shared that through the Data Into Action Project, two consultants from University 

of Oklahoma’s College of Public Health implement three workshops each year, with each 

including between 20 and 25 attendees. Workshop leaders use a hand-on approach to show 

participants strategies to find good data sources and types of data that might be helpful for 

different programs. Workshops have been held in Oklahoma City, Oklahoma(twice); 

Albuquerque, New Mexico; Denver, Colorado; Oakland, California; and Phoenix, Arizona. To 

date, they have reached approximately 200 attendees. In addition, a hands-on grant writing 

workshop aims to help attendees write strong grant proposals. The evaluation ratings for the 

Data Into Action workshop and the grant writing workshop have been positive. In 2018, AAIP 

will offer three more workshops in the eastern US region, possibly focusing on tribes in North 

Carolina, the New England area, or the Great Lakes region.

Ms. McDaniel presented more details on AAIP’s grant writing workshop. AAIP worked with June 

Strickland, PhD, RN, professor at the University of Washington, to develop the grant writing 

workshop curriculum and to implement it in tribal communities. She developed several training 

modules in a train-the-trainer style, which are now available online. Dr. Strickland implemented 

in-person workshops in Oklahoma City and at the University of Washington. They learned that a 
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one-day training was not enough time to go through the intensive training process. Postworkshop evaluations revealed that although people were gaining knowledge, the period was 

still too short for the attendees to grasp the concepts for developing effective proposals. 

In response, AAIP partnered with the Agency for Healthcare Research and Quality’s Office of 

Minority Health (OMH) Resource Center to provide facilitators who had already developed a 

curriculum geared towards tribal communities. Their program is called “Vision, Design and 

Capacity,” and it incorporates several group exercises that are aimed at different components 

of a grant proposal. AAIP offered a 21⁄2 day grant writing workshop in conjunction with the 

recent HHS Region 6 Tribal Consultation Session in May 2017. It reached twice as many 

attendees from tribes and tribal organizations. The topics included an overview of problem 

statements, the components of logic models, how to write SMART (specific, measurable, 

achievable, results-focused, time-bound) objectives, and resources for finding funding 

opportunities. The facilitators also encouraged attendees to look at “cycles of funding” so their

activities and funding amounts are consistent and steady. The post-workshop evaluations were 

very positive with a few recommendations to shorten the course length to two days.

Ms. McDaniel described the Healthy Active Native Communities Project for which AAIP is 

partnering with tribal health departments and tribal organizations that have an interest in 

preventing obesity. The project adapts CDC’s evidence-based strategies to improve nutrition 

and increase physical activity for tribal communities. 

With a focus on policy systems and environmental changes, eight communities have been 

funded to incorporate ten strategies to increase fruit and vegetable consumption and ten

strategies to increase physical activity. As one example, the Absentee Shawnee Tribe used AAIP 

funding to incorporate two 10 to15-minute breaks in the course of a workday and add a social 

support component. The tribe had an existing physical activity policy, which allowed tribal 

employees to use three hours paid leave to either use the tribe’s fitness facilities or a 

preapproved offsite facility, but interest eventually dwindled over time. As indicated in CDC’s 

Winnable Battles initiative, programs with a participant support component are more effective. 

At Absentee Shawnee, the employees turn in walking logs, and have monthly incentives and 

awards ceremonies. The tribe also modified the policy language from “exercising for fitness” to 

“exercising for health,” which survey responses indicate is more favorable.

A village in Alaska enhanced its exercise facilities through community buy-in and participation. 

They reached out to elders to help name the facility in the Yupik language and incorporated 

symbols for marketing purposes. They included community members to repaint the facility and 

set up the exercise equipment, and they held a grand opening. They also implemented a fiveweek fitness challenge. The village found that community members equated using the facility 

with “If you’re healthy, you can fish more, and you can enjoy outdoor activities when your body 

is in a better physical condition.” The physician who visits periodically also encourages its use

for rehabilitation purposes.
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The Indian Child and Family Preservation Program is an Urban Indian program based in 

California. It conducts work related to Indian Child Welfare Act compliance and supervised 

visits. The program also does outreach activities using an intergenerational approach, including 

working with an education and development program to develop three acres of land for 

community gardening and a recreational facility. They worked with elders to impart knowledge 

about traditional plants, to share their histories with families, and to convey the importance of 

physical activity.

The Oklahoma Indian Clinic, an Urban Indian program, is providing a space for children to be 

more physically active. The space was primarily designed for people ages 13 and up, but when 

they found that children visiting the clinic were either obese or overweight, they decided to 

modify the space to make it suitable for children too. Pediatricians refer the children and 

individuals who work at the clinic staff the space and lead individual and group sessions. They 

also offer nutrition classes.

The Sacramento Native American Health Center, an Urban Indian Center, is implementing 

community and home gardens. They are focusing on young families, and patients with diabetes 

and hypertension. Their activities include hosting a series of workshops that involve growing 

your own food, and vouchers for the farmers market. The health center has found that 

participants developed their own health goals and had questions for their health providers or 

health educators. This presented an opportunity to combine medical services with social 

services, which had never been done previously.

A common theme across participating tribes and tribal organizations is that partnerships were 

crucial to the success and sustainability of the projects. AAIP’s technical assistance to the subgrantees, along with buy-in from leadership and the community to sustain the programs either 

through memoranda of agreement, memoranda of understanding, policies, etc. 

Councilman Antone opened the floor for questions. 

One attendee asked if the Grant Writing Workshop is in a “train the trainer” format.

Presenters answered that the first modules were in a train-the-trainer format, but since AAIP 

started partnering with the Office of Minority Health, the training is in a more direct training 

format. The web-based train-the-trainer modules are still available. 

Councilwoman Carlyle asked if the tribes in Arizona work with the Inter-tribal Council of Arizona 

TEC, and if presenters know if anyone from that organization has attended the grant writing 

trainings.

Presenters responded that AAIP is planning to offer two or three more trainings before funding 

ends in 2018, so those interested can make a request to have a training in their area. 
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Councilman Antone concluded the session. 

Tribal Partnerships for Enhanced Emergency Preparedness 

Panel participants 

• Jeff Morris, MPH, Institutional Environmental Health Officer, CNDH

• Mendy Spohn, MPH, Administrative Director for Health Departments, Oklahoma State 

Department of Health

Ms. Spohn started the panel by stating that three years ago the Oklahoma State Department of 

Health collaborated with the Chickasaw Research and Population Health program on a 

community-wide project to reduce the incidence of influenza hospitalizations and deaths. The 

project helped identify roles and responsibilities, data storage, and definitions. Because the 

outbreak occurred on Trust Lands, it involved several health departments, school systems, and 

employee worksites, and it taught an important lesson about who to reach out to during an 

outbreak. Because of a learning curve regarding how to coordinate efforts best across several 

organizations, infectious disease nurses from Chickasaw and the Oklahoma State Health 

Department now regularly meet to ensure tracking and effective communication of potential 

health issues.

In addition, Ms. Spohn shared that to continue building their skills, her department is working 

in Carter County, Oklahoma, on a full-scale exercise on mass immunization and prophylaxis. 

Oklahoma State Health Department has been practicing and training on such topics across the 

state for the past 15 years. Ms. Spohn stated that her department is now capable of setting up 

a clinic within an hour. However, they are concerned about setting up an incident management

system. 

In addition, Oklahoma State Department of Health is working to increase risk communication 

capabilities by creating or designating liaisons between incident command and hospitals, city 

and county governments, and school systems. Ms. Spohn explained that this creates a channel

for communications on a local, regional, or national level to manage any potential outbreaks or 

the need for medicine or vaccine distribution, and builds a broader and more accessible public 

information platform. Ms. Spohn concluded by emphasizing that building relationships and 

remaining active in daily activities is the core to providing effective preparedness and response. 

Dr. Montero commented that it was great to learn about a model where tribal, state, and local 

health departments are working together. He asked panel members to specify what makes 

their collaborative efforts successful. 

Mr. Morris responded by stating that the Oklahoma State Health Department and CNDH have 

established personal relationships and intentionally broken down social barriers by training 

together and sharing information. 
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Dr. Montero asked the panel members how CDC could institutionalize a program such as theirs. 

Ms. Spohn responded by stating the following tactics:

• Establishing policies 

• Creating a plan that is easy to follow regardless of who holds different roles 

• Building an MOU to help institutionalize programs 

• Defining the urgency of issues at hand and working to address them effectively 

She went on to recommend developing relationships early to set up the infrastructure, so it will 

carry on. Emergency management or response is not just about inspecting damaged buildings 

or public health infrastructure, it is about people. 

Dr. Montero asked what CDC could do beyond funding to support efforts like this, or to step 

aside.

Ms. Spohn suggested that CDC build flexibility in program guidelines or grant applications, and 

be less prescriptive with requirements like forms. She went on to suggest CDC focus on what 

the ultimate goal is, such as for communities to be ready—to be able to access the Strategic 

National Stockpile, get medications to the right people within 48–72 hours, document and track 

that distribution in case there might be a recall on the medications or something, and 

communicate risk well. Looking back 15 years, Ms. Spohn remarked that having funding 

opportunities and the training really helped, and that flexibility—however that can be done—is 

good.

Navajo Area Authorized Representative Del Yazzie, Acting Director, Navajo Epidemiology Center

commented that Navajo Nation, with three state borders (New Mexico, Arizona, Utah), has 

made strides in building relationships with those states and the counties within them. Navajo 

Nation is working to coordinate on public health emergencies, communicable diseases, 

environmental health assessments, and outbreaks. He asked if the presenters have a flow chart 

for communications for how different cases could be managed. He went on to say that at 

Navajo Nation, responding to emergencies in a coordinated fashion is a challenge, and that they 

need protocols for samples that are sent to the state health departments and/or CDC. Navajo 

Nation has tried to develop a flow chart based on what a patient would go through.

Ms. Spohn replied that mind mapping software is a good tool, and that it’s helpful to think 

about the public health message, and if it gets complicated, to start scheduling meetings with 

partners to figure out roles and responsibilities and top issues that need to be addressed 

immediately. She has some logic models that she would be happy to share.

Mr. Morris also responded that disseminating accurate information is key. He recommended 

establishing a unified command and use media e.g., radio, TV) to get messaging out. 
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Councilman Antone added a response to Dr. Montero’s questions, stating that funding to tribes 

and allowing for flexibility is important. Whether funding goes directly to tribes or through 

states, it is important to know what the expectations are and where the accountability is. Even 

if Congressional language restricts funds to certain entities, tribes might still be able to obtain 

some of that funding; however, restrictions can also hurt tribes too. He stated that hearing 

from the tribes today, it is not about money—it’s about changing policy. The CDC Director or 

HHS Secretary might have broad authority to implement Memoranda of Understanding (MOUs) 

that help to get the funding and other resources to tribes. 

Councilman Chester Antone concluded the session. 

Oral Tribal Testimony

Mr. Yazzie presented the first tribal testimony. He thanked CDC representatives for addressing 

Navajo Nation’s concerns and needs. Mr. Yazzie requested that written testimony to be 

imported into the meeting minutes. As a result, all written testimonies are included as 

appendices to this document. 

Mr. Yazzie noted that Navajo Nation applied to be a CDC PHAP host site and hopes to get their 

first PHAP in October 2017. 

Chickasaw Nation Representative, Judy Goforth Parker, Secretary of Health for Chickasaw 

Nation, provided a testimony. She thanked CDC and ATSDR staff for their presence and support 

at the Summer 2017 TAC Meeting. Secretary Parker stated that her background is in nursing 

and teaching public health, and that tribal public health accreditation is one of Chickasaw 

Nation’s priorities. She addressed a question regarding preparedness activities and state and

tribal relations. Secretary Parker emphasized the role of the tribal liaisons within various 

departments in Oklahoma. Tribal liaisons answer questions for states on behalf of tribes and 

vice versa. The relationship between states and tribes depends on the communication carried 

out by the tribal liaisons. She emphasized that continuous, bidirectional outreach in a 

professional relationship is extremely beneficial in attaining goals. She concluded by 

highlighting the following items from Chickasaw Nation’s written testimony: 

• Make funding to tribes secure and sustainable—ensure funding streams to tribes, even 

if it takes Congress to make this happen. 

• Increase tribes’ access to compete for funding. For example, identify where a tribe can 

have direct eligibility and facilitate their competitiveness in the application process.

• Ensure a tribal voice in the larger CDC system by better understanding the role of 

OSTLTS and TSU. 

• Report on CDC funding streams that are restricted through legislative language. 
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• Remain cautious on specificity in grant opportunities. 

• Acknowledge the Tribal Behavioral Health Agenda, which empowers Chickasaw Nation 

to do great things in integrating services for our nation. 

• Understand Chickasaw Nation shares common concerns, goals and visions in public 

health and behavioral health. 

Chairwoman Andrews-Maltais provided testimony on behalf of her tribe. She reiterated the 

need for direct funding, and specifically requested additional funding or assistance to combat 

Lyme disease. Chairwoman Andrews-Maltais explained that there are no natural predators to 

the deer population in her area. In addition, her tribe has seen many false negatives when 

testing for Lyme disease, and improved diagnostic testing is needed. Some individuals in her 

tribe are identified as having Lyme disease 15–20 years after contracting the illness. She 

requested that CDC conduct an island-wide survey or study of Lyme disease. She concluded by 

stating that we need to be able to learn more about treatment process and CDC guidelines, and 

that follow-up to this request will impact IHS and Purchase/Referred Care dollars. 

President Edwardson stated that he has pursued building a hospital for 18 years, and that his 

clinic cannot treat cancer patients. He stated that among eight communities, his tribe lost on 

average one member to cancer every three days consecutively for a year and eight months, a 

significant loss for a population of only 13,000. He explained that he would like to add an entire

floor as a treatment clinic. 

In addition, the Inupiat community has two contaminated rivers that cause fish to die, making it 

hard for villages that rely on fishing as a source of food to feed themselves. President 

Edwardson listed the following additional issues:

• Arrival of foreign ships is creating a risk to the national security of the community

• Assistance in protecting the North American salmon in the artic as fish are killing the 

salmon

President Edwardson concluded that his biggest request is the third-floor construction of a 

cancer treatment clinic. The Mayo Clinic is willing to provide his community with staff to treat 

the patients if a building is available for them to work in. He reiterated that his community is in 

dire need of this assistance because people are dying. 

Ms. Fourkiller thanked Dr. Bauer for taking an additional day to visit and for visiting Indian 

Country in general. She reiterated what TAC members previously said about funding 

mechanisms, and that activities proposed in NOFOs are highly beneficial but will not be 

executed if tribes lack funds to do so. Ms. Fourkiller also emphasized the need to develop a 

long-term plan for developing such activities in Indian Country. 

She stated that with the help of a small team in Oklahoma, NIHB is developing a public health 

capacity scan. The following themes recur in discussions regarding the scan:
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• Tribes request data on tribal and federal resources invested in public health 

• Tribes are hesitant to report financial data

Ms. Fourkiller recommended that NIHB remove financial questions from the scan to ensure a 

greater response from individuals in Indian Country. 

Councilwoman Carlyle shared that the Phoenix Area consists of 42 tribes across the states of 

Arizona, Nevada, and Utah. Councilwoman Carlyle stated that the Nevada TEC sends

information out via the Inter Tribal Council of Arizona (ITCA). Using surveys that reach tribal 

communities, the ITCA shortlisted a few priorities, including ACA and the IHS National 

Community Health Program. Several tribes have developed a community-based action plan to 

assess the effectiveness of community public health programs. A top priority in the Phoenix 

area is to serve all AI/AN individuals, and avoid limiting community health services to those who 

do not live on reservations. Additional priority areas include mental health, oral health, urban 

health, and the sanitation facilities construction. 

Councilwoman Carlyle elaborated on the survey sent out to tribal communities. The survey 

included questions about data quality improvement and community profiles of health statistics. 

Councilwoman Carlyle concluded by recommending that CDC address and respond to each

priority by collaborating with tribes to collect data. She stated that although there will never be 

enough funding, accurate data has the power to increase tribal health funding. 

President Andrew stated Alaska Area priorities: substance abuse, unintentional injury, adverse 

childhood experiences (ACE), cancer prevention and control, diabetes prevention and access to 

clean water. President Andrew explained that Alaska’s main issue is that the state does not 

recognize the tribes, creating a barrier to accessing accurate tribal health data. She concluded 

that the CDC can assist the Alaska area by providing TECs with access to data. 

Ms. Pivec started her testimony by stating that CDC can continue to fund and utilize the TAC to 

its fullest potential. Ms. Pivec suggested:

• Holding an annual, in-person meeting between the CDC director and TAC members 

• Assigning a tribal liaison position within each CDC CIO

• Creating a dedicated and formal tribal seat at the CDC EOC

• Including TAC members and tribal leaders in the internal budget process 

• Formalizing a tribal budget formulation process 

In addition, Ms. Pivec emphasized the need for public health services that are tailored for tribal 

communities. She expressed concern about the current public health capacity scan, explaining

that it will not provide more information than we already know, which is that tribal 

communities need more public health infrastructure. Ms. Pivec concluded by stating that 

Cherokee Nation is committed to working with CDC and NIHB to build public health 

infrastructure. 
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Councilman Antone provided his testimony by reiterating the following past requests made to 

CDC:

• Allocate 2% of each CIO’s budget to Indian Country

• Improve language that can be used for legislative appropriations and explore how public 

health services can be provided with language that CDC is responsive to

Councilman Antone also stated that OSTLTS could proactively educate each CIO as well as the 

CDC director on tribal priorities. He suggested that OSTLTS could facilitate a meeting for TAC 

members to discuss tribal priorities with the new CDC director, Dr. Brenda Fitzgerald, within her 

90-day review period. He acknowledged that Dr. Fitzgerald would consider requests from 

OSTLTS and other CIOs. Councilman Antone also supported the idea of OSTLTS continuing to 

support the TAC by holding an annual meeting with the CDC director. Regarding public health 

infrastructure, Councilman Antone requested that the new CDC Director use maximum 

discretion when it comes to tribal funding. 

He acknowledged that the GHWIC grant has an evaluation component and emphasized the 

importance of analyzing evaluation results. In response, Dr. Montero stated that he would

check and see if University of South Dakota is in charge of the evaluation results. 

Councilman Antone stated that Arizona is having issues with their state legislature submitting 

the Sunrise application due September 1, 2017. Arizona’s Sunrise review process provides a 

mechanism for healthcare professionals to request regulation or expansion in scope of practice.

Lastly, Councilman Antone reminded participants that Zika virus is still affecting tribal 

communities. CDC and tribal communities should continue to be mindful of the impact of the 

Zika virus. 

Representative TwoBears gave the final tribal testimony. He acknowledged that the Bemidji 

Area has been consulting with the federal government for a while. He stated that Ho-Chunk 

Nation of Wisconsin has an organization called the Midwest Alliance of Sovereign Tribes 

(MAST), which includes tribes in the states of Minnesota, Iowa, Michigan and Indiana. He stated 

that MAST needs a technical advisor to assist with issues such as health disparities, chronic 

diseases, and diabetes. In a recent regional consultation, the top issues in the Midwest were

opioid use and heroin overdose. Representative TwoBears stated that the issue is that tribes 

are relatively new to addressing such issues and may not always know how to address them. He 

reiterated that his tribe and area are looking for advice and assistance in addressing public 

health concerns, and added that some tribes do not have the means to travel to meet with 

technical advisors. 
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Closing prayer/Adjournment 

Dr. Montero thanked Councilman Antone for running the meeting and thanked everyone for his 

or her input, recommendations, and ideas. He stated that CDC has been continuously improving 

the way it manages TAC meetings, and that it will continue to do that to make the most of TAC 

delegates’ time. 

Captain Clelland thanked the Chickasaw Nation hosts for their gracious hospitality. He also 

instructed those on federal travel orders to send their receipts to Tyeece Marshall by Friday 

August 18, 2017. CDC’s Winter TAC will be Feb 6–7, 2018. 

Councilman Antone thanked the state of Oklahoma and tribes. 
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Participants

Tribal Advisory Committee Members

• Alicia Andrew (Karluk IRA Tribal Council): President, Karluk IRA Tribal Council; Alaska 

Area Delegate 

• Robert Flying Hawk (Yankton Sioux Tribe): Chairman, Yankton Sioux Tribe; Great Plains 

Area Delegate

• Robert TwoBears (Ho-Chunk Nation): Legislative District V Representative, Ho-Chunk 

Nation; Bemidji Area Delegate

• Jonathan Nez (Navajo Nation): Vice President, Navajo Nation, Co-Chair, Tribal Advisory 

Committee; Navajo Area Delegate

• Lt. Governor Jefferson Keel (Chickasaw Nation): Lt. Governor, Chickasaw Nation; 

Oklahoma Area Representative 

• Delia Carlyle (Ak-Chin Indian Community): Councilwoman, Ak-Chin Indian Community; 

Phoenix Area Delegate 

• Travis Brockie (Lummi Nation): Council Member, Lummi Nation; Portland Area Delegate 

• Chester Antone (Tohono O’odham Nation): Councilman; Tohono O’odham Nation, 

Chair, Tribal Advisory Committee; Tucson Area Delegate 

• George Edwardson (Inupiat Community of the Arctic Slope): President, Inupiat 

Community of the Arctic Slope; Delegate-At-Large 

• Byron Larson (Northern Cheyenne Tribe): Tribal Employee, Northern Cheyenne Tribe; 

Delegate-At-Large

• Bryan Warner (Cherokee Nation): Tribal Councilor, Cherokee Nation; Delegate-At-Large 

CDC and ATSDR Senior Leaders

• Ursula Bauer, PhD, MPH: Director, NCCDPHP, CDC 

• Stephanie Dulin, MBA: Deputy Director, NCBDDD, CDC

• José T. Montero, MD, MHCD: Deputy Director, CDC; Director, OSTLTS, CDC

CDC and ATSDR Participants

• Captain Carmen Clelland, PharmD, MPA, MPH: Associate Director for Tribal Support, 

OSTLTS, CDC, (Cheyenne and Arapaho Tribe)

• Commander Damion Killsback, PharmD, MPH: Deputy Associate Director for Tribal 

Support, OSTLTS, CDC, (Northern Cheyenne Tribe) 

• Gregory Smith, MPA: Tribal Liaison Officer, Program Services Branch, Division of State 

and Local Readiness, OPHPR, CDC

• Joel Kimmons, PhD: Health Scientist, Division of Nutrition, Physical Activity and Obesity, 

NCCDPHP, CDC 

• Georgia Moore, MS: Associate Director for Policy, OSTLTS, CDC

• Jillian Doss-Walker, MPH: Public Health Advisor, IHS Immunization Program Field 

Assignee, CDC
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• Victoria Phifer, MPH: Public Health Analyst, Office of Public Health Scientific Services 

Office, CDC
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Appendices 

(Click to open each .pdf file to read the full report) 

Alaska Area Delegate, Area Report
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Written Testimony of California Rural Indian Health Board

Written Testimony of Cherokee Nation
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Written Testimony of Chickasaw Nation
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Written Testimony of Navajo Nation
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Written Testimony of the Osage Nation
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Acronyms

AAIP Association of American Indian Physicians 

ACA Affordable Care Act 

AI/AN American Indian/Alaska Native 

ASI Accreditation Support Initiative 

ATSDR Agency for Toxic Substances and Disease Registry

BMI Body Mass Index 

CDC Centers for Disease Control and Prevention 

CIO Center, Institute and Offices 

CNDH Chickasaw Nation Department of Health 

DRH Division of Reproductive Health 

EOC Emergency Operations Center 

FY Fiscal Year 

GHWIC Good Health and Wellness in Indian Country

HHS Department of Health and Human Services

IAA Interagency Agreement 

IHCIA Indian Health Care Improvement Act 

IHS Indian Health Service 

IRB Institutional Review Board 

ITCA Inter-Tribal Council of Arizona 

MAST Midwest Alliance of Sovereign Tribes 

MOU Memorandum of Understanding

NAS Neonatal Abstinence Syndrome 

NCBDDD National Center for Birth Defects and Developmental Disorders

NCCDPHP National Center for Chronic Disease Prevention and Health Promotion 

NCIPC National Center for Injury Prevention and Control

NCHHSTP National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention 

NIHB National Indian Health Board

NPHII National Public Health Improvement Initiative 

NOFO Notice Of Funding Opportunity

OPHPR Office of Public Health Preparedness and Response

OSTLTS Office for State, Tribal, Local and Territorial Support

PHAB Public Health Accreditation Board 

PHAP Public Health Associate Program 

PHPS Public Health Prevention Service 

QI Quality Improvement 

RPMS Resource Patient Management System

SDPI Special Diabetes Program for Indians 

STAC Secretary’s Tribal Advisory Committee

TAC Tribal Advisory Committee 

TEC Tribal Epidemiology Center 
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TSU Tribal Support Unit 

USZPR US Zika Pregnancy and Infant Registry